Protect physicians, patients and the bottom line with a streamlined approach to documentation — Here's how

Incomplete and inaccurate documentation can cause long-term harm and repercussions that can be felt systemwide. Documentation issues can endanger patients and put a practice's financial stability at risk, while unnecessarily increasing physician burnout and causing imperfect resource allocation.

Lucian Newman III, MD, CMIO at Nuance and general surgeon in Gadsden, Ala., and Robert Budman, MD, CMIO at Nuance, explored how artificial intelligence-powered solutions can solve documentation issues during a Nov. 12 webinar hosted by Becker's Hospital Review and sponsored by Nuance.

The complexity of CPT codes contributes to the occurrence of incomplete documentation. Each procedure can have multiple codes associated with it. For example, coding for a thyroidectomy procedure, alone, presents 11 different CPT codes. A slight variance in the procedure's documentation can have ramifications.

For example, if a physician performed an appendectomy with peritonitis, and they coded the appendectomy as an acute appendicitis, the length of stay would be expected to be around 4.3 days on average. The organization would then expect to be reimbursed around $8,700. However, if the proper procedure was selected, the expected length of stay increases to 6.6 days and the hospital would expect to receive around $14,300. Having that length of stay information as soon as the procedure is completed allows an organization to properly implement a postoperative treatment plan and offers a more complete picture of pending reimbursement to plan around.

This scenario could have been further complicated if the surgeon failed to specify what type of appendectomy they performed, or if the coder made a mistake and selected the wrong code, or CMS could have recently implemented a new code and both the surgeon and coder could have been unaware.

AI-powered technology can help avoid these documentation headaches altogether. Nuance Surgical Computer-Assisted Physician Documentation (CAPD) is a surgical documentation solution that improves surgical note completeness, accuracy and billing without disrupting a surgeon's workflow, Dr. Budman said.

"The computer, through AI and natural language processing, is able to read those notes and provide the sophistication and digital suggestion to the physician exactly when they're creating the note," Dr. Budman said. "It's important because the surgeon doesn't have to go back into their memory at a later date and try to remember the exact differences in a patient's procedure."

With the platform, a surgeon can create a fully compliant operative report in the same time it would've taken them to write a brief postoperative note. Implementing the platform improves communication rates among care members, eliminates coding queries and transcription-related delays, and improves time to billing.

Unlike postoperative notes, which get buried in EHR platforms, the postoperative reports the platform creates are sent through the cloud to every person in a patient's care team and are then integrated into the EHR.

Dr. Newman used the CAPD platform for the last 13 years and can't imagine documentation without it.

"I've found it invaluable to be able to navigate the coding changes that are occurring today," he said. "Regardless of the size of your facility, whether it's outpatient or inpatient surgery, a tool build like this can accommodate [both] the mundane procedures, as well as the very complicated procedures. … We're in an analytic world, and this tool can drill down to [fix] the very specific coding issues that face every surgeon."

Nuance Surgical CAPD is consistently updated and always learning. The tool adapts to accommodate a surgeon's unique documentation style, and allows for a complete, postoperative report in under 90 seconds.

View a copy of the webinar here.

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