Engaging surgeons for better documentation

When it comes to documenting procedures, too many surgeons are dissatisfied with the status quo: documentation requirements add to surgeons’ daily burden, coding of procedures is complex and dynamic, and busy days with long procedures can have a negative impact on documentation accuracy. But it doesn’t have to be this way.

Our newest white paper, “How Artificial Intelligence engages surgeons for better documentation,” explores the ways in which smarter technology can help overcome these—and other—points of dissatisfaction. I’ve invited Dr. Lucian Newman III, CMO of Vincari, to introduce you to this white paper.


Accurate documentation of Current Procedural Terminology (CPT) has always been a topic of conversation within physician groups. A large amount of the focus has been on the E/M category used to document history and physical consults, whether inpatient or outpatient. Third-party payers have been augmenting primary care reimbursement in this area, but little attention has been directed to procedural reimbursement with respect to the accuracy of recording by proceduralists.

Each year there are “tweaks” to the value assigned to CPT services, ostensibly to recognize the complexity and value these services deliver. The Relative Value Update Committee (RUC) is made up of 31 physicians who review the presumed value created by services—commonly known as the wRVU, or “work relative value unit,” which has substantial impact on individual reimbursement for physicians. Before 1992, adoption of the Medicare fee schedule changed the model of reference for payment away from the “usual and customary charges” basis for charges. This narrowed the gap between specialist and primary care reimbursement. The RUC sets the value for the wRVU that is used to calculate Medicare reimbursement for CPT services. The payment is a product of wRVU (work) + peRVU (practice expense) + mpRVU x conversion factor where “pe” reflects the costs of maintaining a practice in the area and “mp” reflects the malpractice insurance expense in your specialty and area, and the conversion factor changes yearly based on usage and budget impact. If you are a specialist where minor changes in reporting can change the wRVU substantially, it begs the question: am I missing something?

All physicians are subject to an increasing battery of measurements meant to drive quality, satisfaction, and efficiency. Additionally, protection against fraudulent usage of CPT coding is important. Recovery Audit Contractors (RAC) are directed at curtailing incorrect usage of the CPT reporting for financial gain, and so greater attention is on improving the accuracy and quality of reporting. The focus of procedural reporting should be open and visible to physicians and their complete treatment team to mitigate errors in reporting.

Let’s look at some examples. The excision of skin lesions is among the most mundane of procedures done by primary care and specialists alike. The correct coding of excision is a product of the size of the lesion excised plus the margins on each side required. Waiting for the pathology report (although required to document malignancy) will undersize the correct measurement due to drying artifact – human tissue is roughly 60 percent to 80 percent water by weight. Additionally, there are changes in CPT based on size, and < 5mm, 6 to 10 mm, 11 to 20mm, 21 to 30 mm, 31 to 40 mm and greater than 40 mm. Missing the size by 1mm changes the CPT wRVU!

Similarly, there are 11 different thyroidectomy codes with differing complexity that change the wRVU by more than 100 percent. There are 8 different codes for pericardial intervention with substantially different wRVU values. There are 10 different approaches to prostatectomy. There are 11 different approaches to hysterectomy. The list of variations seems endless, but they are meant to reward physicians performing more involved and complex procedures with better reimbursement.

Those who are interpreting the dictated information – often after a tedious procedure or when your mind has moved on to your next task – are challenged with translating what you did into the correct CPT to get you paid accurately. How often does the surgeon revisit the note after code assignment to assess whether the code and information is reflective of what they did? The nature of most physicians would be to underbill which is also incorrect and unfair to them. Therefore, the question remains: am I missing something?

Check our new white paper,  “How Artificial Intelligence engages surgeons for better documentation,” to find out why surgeons need smarter technology to ensure coding accuracy, enhanced revenue capture, and improved quality ratings.

Dr. Lucian Newman, III is a practicing general surgeon in Gadsden, AL, specializing in minimally invasive surgery. He is a graduate of the University of Alabama’s School of Medicine in Birmingham, and completed a surgery residency at Georgia Baptist in Atlanta in 1993. Dr. Newman practices with his father and brother who are also surgeons; his family has practiced medicine for a total of 119 years.

Over his career, Dr. Newman has given lectures and operated in over 20 countries, published over 100 articles and 6 textbook chapters dealing with minimally invasive surgery, and is currently focused on documentation and coding issues faced by physicians and hospitals alike. Dr. Newman is passionate about creating a more user-friendly environment for physicians to deliver more accurate and complete documentation. Dr. Newman is the current Chairman of Blue Cross Blue Shield of Alabama, Past Chief of Staff at Riverview Regional Medical Center, Past Advisory Board Member at Gadsden Regional Medical Center, Chairman of the Advisory Board for SCA, and Chief Medical Officer of Vincari.


About Michael Clark

Michael Clark is the senior vice president and general manager for Provider Solutions within Nuance’s Healthcare division, leading EHR Services, clinical documentation creation and improvement. A results-driven, accountable leader, Michael aligns organizations to prioritize the customer experience, honor the product roadmap, and execute against the company vision. He has more than 20 years of experience in the healthcare market and a breadth of experience driving and transforming global teams, products, and services. Prior to joining Nuance in 2016, Michael held several executive leadership roles at healthcare organizations including Evariant and MedQuist. Michael holds a B.A. in Marketing and International Business from Miami University and MBA from the University of Miami School of Business.