Side effects of an unhealthy surgical dictionary

Surgical dictionaries are important tools that link clinical documentation to their corresponding administrative codes, which are necessary for billing and regulatory reporting needs. But these standardized codes are not static, which means effective dictionaries require continuous upkeep. And when a surgical dictionary becomes unhealthy – with outdated or inaccurate codes – there are several side effects that can negatively impact organizations.
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Surgical dictionaries are one of the fundamental building blocks within the EHR that help support an organization’s core functions – like quality reporting, reimbursement, and patient care. But, to remain effective, surgical dictionaries must undergo regular coding upkeep. In a previous article, we explored a few symptoms that may indicate an unhealthy surgical dictionary such as:

  • Missing terms where providers can’t find the clinical terminology they need during clinical documentation
  • Ambiguous terms that don’t fully capture a patient’s condition, leading to inaccurate records
  • Inadequate terms for proper and accurate documentation
  • Outdated or incorrect code mappings

And just like any illness, these symptoms of a poorly maintained surgical dictionary 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If a surgical dictionary has outdated or missing terms, the clinical workflow to document procedures quickly becomes inefficient and frustrating for providers. But when well-maintained, this tool can be intuitive and aid clinical documentation workflows, not hurt them.

Poorly maintained or absent CPT codes

Correct 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 for being submitted with insufficient information. This can result in billing departments needing to track down surgeons in order to get the complete clinical documentation needed to map to administrative codes. 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 that may require 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 that perform thousands of cases each year. An updated surgical dictionary is critical to making block time work.

Preference card management

Preference cards are lists of the specific tools, supplies, and equipment that a 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 create 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.

For the antidote to these side effects, 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.

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