Minor Surgery but Not Minor Documentation – Retinal Physician

To avoid payment denials, make sure your chart notes include the “how” and “why” of each procedure.

To some people, the term minor connotes something unimportant or inconsequential. From this connotation, it’s a short step to a brief chart note that hardly supports the reasons for a minor procedure. But minor surgery is not trivial, and the chart documentation must support it by including what was done and why. Without adequate notes, third-party payers may rescind payment for the service. This month’s column answers some important questions about minor surgery documentation.

  • What defines a minor procedure?
  • What should be included in the medical record for a minor procedure?
  • Is additional information required if the minor procedure involves use of a laser?
  • Should consent be documented as part of the operative report for minor procedures?

This article was published in Retinal Physician, which is written by written by Corcoran’s Associate Consultant,Brandy H. Sperry, COMT, CPC, COE, CPMA. To view the entire article in Retinal Physician, click on the link below:


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