Operating room efficiency depends upon many factors, one being an accurate surgical dictionary. This tool is one of the fundamental building blocks working within the electronic health record (EHR) that helps support an organization’s core functions – like quality reporting, reimbursement, and patient care. However, to remain effective they must undergo regular coding upkeep. Surgical dictionaries link a clinician’s documentation to the appropriate standardized codes, which are regularly revised and updated. Because of this, keeping your organization’s surgical dictionary current and correct can be challenging without the support of third-party terminology solutions.
Indicators of an unhealthy surgical dictionary
Not sure if your organization’s surgical dictionary is good enough? Here are some symptoms of a dictionary that might need improvements:
- Missing terms: Can providers easily find the clinical terminology they need during clinical documentation?
- Ambiguous terms: Do terms fully capture a patient’s condition, or are providers selecting descriptions that are “close enough”?
- Inadequate terms: Are terms robust enough for accurate documentation?
- Outdated terms: Will clinicians be able to use the most up-to-date terminology with current code mappings?
Just like any illness, these symptoms have various side effects that can impact the core organizational functions that the tool is intended to support.
Side effects of an unhealthy surgical dictionary
Difficult to search for and select procedures
If a surgical dictionary has outdated or missing terms, the clinical workflows used to document procedures quickly becomes both inefficient and frustrating for providers. But when well-maintained, this tool can be intuitive and streamline EHR workflows, not hurt them.
Poorly maintained or absent CPT codes
Accurate CPT® codes are key to securing prior authorization, which is critical to ensuring a procedure is approved by the patient’s insurance. Without the correct codes, insurance providers may deny surgical claims based on insufficient information. This can result in billing departments spending time to track down surgeons for more information. In a worst-case scenario, problems with prior authorization can even prevent a surgery from happening completely.
“Close enough” scheduling
Without granular clinical terms, a surgery requiring four hours to perform may be documented with a “close enough” code that only blocks off the operating room for two hours. This error can quickly compound when you consider the hundreds of surgeons performing thousands of cases every year. An updated surgical dictionary is critical to making block time work – don’t settle for “good enough” or “close enough”.
Preference card management
Preference cards are lists of the specific tools, supplies, and equipment that each individual surgeon prefers to use for a particular type of surgical case. Duplicative or missing terms in a surgical dictionary can lead to incorrect or outdated preference card information. And since preference cards are employed to set up the OR for success, any inaccuracies can add to frustration and delays when surgeons don’t have the tools they need.
Poor procedure time averaging
To support the creation an efficient surgical schedule, providers need accurate surgical dictionaries that support the ability to document how long surgeries take – presently and over time. If schedules are developed with administrative codes that incorrectly reflect procedure types, times, and needs, the schedule is ineffective and can cause ongoing workflow challenges.
Surgical dictionaries: A success story
Still not convinced that your surgical dictionary has that big of an impact on your organization’s workflows? Think again. When Piedmont Healthcare partnered with IMO, they learned just how valuable an well-managed surgical dictionary could be.
As Piedmont expanded, they realized that their newest locations didn’t always speak the same language when it came to surgical terminology and procedure codes. Furthermore, procedure terms were not mapped to Current Procedural Terminology (CPT®) codes that help ensure accurate scheduling and prior authorization approval.
But once they integrated IMO Core Periop – a surgical terminology and scheduling solution – into their EHR system, they were able to quickly streamline the maintenance of procedure terms and codes in their surgical dictionary. This helped Piedmont improve scheduling workflows, reduce denied prior authorizations, and easily identify inpatient-only procedures at the time of scheduling. Having each term accurately mapped to corresponding CPT codes made a substantial positive impact throughout the organization. Read the full case study here.
For more on the impact of terminology on operating room efficiency, watch our on-demand webinar, Why the health of surgical dictionaries matters.
CPT is a registered trademark of the American Medical Association. All rights reserved.
