Follow these post surgery steps/guidelines. This will ensure your billing is error free. It also ensures there are less complications after a surgery.
- Get the operative note needed for billing
On the day of the surgery, ensure that you also deliver a surgery package to your surgeon.
This is a back up – just in case the surgery center / hospital is missing any paperwork (I have seen that happen a few times).
After the surgery, ensure that your surgeon hands you the operating note. You are going to need this for billing.
- Get the pre and post operative diagnoses
Ensure that the operative note has enough information and highest levels of specificity for you to be reimbursed in full without any denials.
Make sure that the note contains both the pre-op and post-op diagnoses (just in case it has changed).
- Get the CPT terminology (not just CPT code)
Operative note contains CPT terminology as much as possible but not the CPT code itself (sometimes, this clashes with billing codes)
- Get indications for surgery and complexity
The note has at least a few sentences about “Indications for Surgery” that your coders can use.
Surgeon’s operative note has “Complexity” section that buttresses your claim for payment
- Get detailed “description” of the surgery
Finally, the note, of course, has to have the description of the surgery
- Follow up with patient the day after surgery
Following up with a patient after the day of surgery to ensure no complications occurred is CRUCIAL.
You or the surgery scheduler needs to make that part of their workflow for the patient as well.
- Followup withoperative care instructions
Usually, the surgery center does provide all post operative care instructions, however, care instructions specific to your speciality should be followed through by you or someone in your team.
This could include the medications the patient can and cannot take, the correct way to take medications, wound care, the appropriate emergency contact information that the patient needs.
- Make sure the patient shows up for post-op
The surgery scheduler should also ensure that the patient does show up for their post-operative appointment the next day after the surgery.
If your surgery scheduler cannot do it, make sure your call center or front-desk calls the patient to show up.
- Remind patient about 1 week post op appointment
When the patient shows up for their post-op appointment, make sure that the patient has follow up appointments.
I recommend post operative appointments one week after surgery, one month after surgery, and three months after the patient’s surgery.
As the patient shows up for each follow up appointment, remind them of the next appointment.
- Get patient reviews
Technically speaking, this is not really a post operative workflow.
However, in my experience, the day after the surgery is typically the best time to follow up with a patient satisfaction survey 🙂
You want more reviews, don’t you?