Supportive documentation for procedure notes

Don’t let speed lead to insufficient documentation.

When you first learn the task, you painstakingly follow each action point, execute it, think about the next step, and so on. Gradually, you know the steps and the task becomes second nature.

For providers in your practice, the process is similar. They started their careers as students learning how to perform refractions, slit lamp exams, or cataract surgery. Over time, they became more proficient in their knowledge and skills — what had seemed difficult or challenging was rote. The same can be said for documentation.

The slippery slope to minimal documentation

Whether your practice providers are in their first job or have been in the eye care for 30 or 40 years, they all follow general requirements for documentation. As they better understood the “what” and “why” of documentation, they developed better, and less cumbersome, ways of recording their services in the medical record.

For staff members, the process of learning how to document is similar. As you learn more about documentation requirements for office visits, diagnostic testing, or procedures, the ability to quickly do so increases, and providers and staff develop a “shorthand.”

For example, when routine use intravitreal injections started in early 2005, the documentation for the injection was substantial. The procedure notes typically included the prep process with betadine, the anesthetic used and how it was administered, the draping of the patient and insertion of the lid speculum, the eye, the drug used, the exact location of the injection, postoperative notes, and more. Over time, the number of documented details eroded. Practices created a shorthand for the drug and procedure, such as IVL for “intravitreal Lucentis.” As a consequence, the slippery slope resulted in some practices using only “IVL OS.”

The auditor perspective

For auditors, especially those who are unfamiliar with eye care, the different documentation styles, symbols, and assumptions can create a situation in which the service is considered “insufficiently documented” resulting in denied payment or demanded recoupment. To avoid this problem when documenting procedures, provide supporting documentation that clearly indicates the service took place.

Repeated procedures

Some common issues with procedure documentation involve intravitreal injections, lasers, and other in-office procedures. These procedures contain a required set of steps. As providers perform the services again and again, the documentation supporting the services tends to become shorter and shorter with less content and fewer details.

For example, if you saw a procedure note for a YAG OS with “532 0.1 sec 50µ” as the procedure note, would you be able to state the documentation supported the procedure billed? To someone in the ophthalmology/optometry space, that answer is most likely “yes.” But, to an auditor unfamiliar with the language and settings, the procedure note only provides data and does not describe a procedure.

Procedure note tips

An in-office procedure note should read similar to an operative note done for the ASC — as a procedure note. For example, “Patient seated at the slit lamp, chin placed on chin-rest. A contact lens was placed against the cornea with Goniosol,” and so forth. The procedure note should be more than just numbers jotted down on a piece of paper without interpretive meaning.

Additionally, while the process with EHR is simpler, take notice to ensure the documentation of the procedure is accurate. For example, if the procedure template in the EHR says the physician used a wide-angle lens but he used a mirrored lens in this instance, the documentation should reflect it. OP