P33 – Dictation, Coding, and Billing Accuracy: A Case Study in Skin and Soft Tissue Procedures

Author(s):
Erik Askenasy, David Berger, Bradford Scott, Lillian Kao, Mike Liang, Baylor College of Medicine

Background: Operative reports which do not reflect the key components required by payors and current procedural terminology (CPT) may lead to significant reductions in reimbursement. Often the requirements and CPT codes are complicated and nebulous such as for skin and soft tissue (SST) procedures.

Hypothesis: Surgeon operative reports do not accurately reflect the key components of the procedure performed and consequently results in a significant decrease in potential reimbursement for skin and soft tissue surgeries.

Methods: Fifty consecutive patients undergoing SST procedures at an urban safety net hospital were evaluated. The operative reports were reviewed and assessed for five elements necessary to meet criteria for excisional debridement. Original relative value units (RVU) and charge values were obtained and compared to ideal RVU and charge value had the operative report been complete.

Results: The overall accuracy of the dictated operative report for SST surgeries was 30%. When looking specifically at excisional debridements the accuracy rate dropped to 13%. Size and depth of the wound were elements most likely left off the operative report. Had the operative reports included all necessary components, RVU generation and charges would have doubled.

Conclusions: The dictated operative report for SST surgeries does not contain many of the necessary elements. A potential increase in productivity measures can be accomplished by more complete and thorough dictations.