When minutes – and details – slip through the cracks
In the surgical environment, small breakdowns carry big consequences. Clinical delays may be unavoidable, but preventable inefficiencies such as inaccurate scheduling, incomplete documentation, or coding gaps create friction across teams, impacting billing, reimbursement, and revenue cycle performance. What begins as a documentation issue in the operating room (OR) rarely stays there.
From a financial perspective, the stakes are high. Roughly 60-70% of hospital revenue is generated in the OR, however, it accounts for up to 40% of total hospital expenses.1 That imbalance leaves little margin for error. But every day inaccurate case estimates disrupt schedules. Claims are delayed and denied. Missing laterality and site of care designations force manual coding review. (And when a surgery is performed in the wrong setting, the financial loss cannot be undone.)
At the center of these challenges is a shared root cause: point-of-care documentation that fails to consistently capture the necessary level of specificity and clinical intent. In this insight brief we explore how a highly granular, up-to-date surgical dictionary can serve as the foundation for operational efficiency and financial integrity, supporting accurate scheduling, compliant billing, and every step in between.
[ SURGICAL SCHEDULING ]
Broad surgical terms may be clinically accurate but operationally risky. Take “craniotomy,” for example. That single term can represent procedures lasting 90 minutes or more than 210 minutes – a two-hour swing in case duration. When cases are scheduled using generalized or averaged time estimates, that variability compounds quickly.
Financial implications
If five craniotomy cases are scheduled at a 150-minute average but are actually shorter procedures, the organization could block 300 minutes (five hours) of unused OR time, costing up to $18,000. If cases run longer than scheduled, those same five procedures can generate five hours of unplanned overrun time, costing more than $11,000 and delaying subsequent surgeries.
A leading regional academic health system operating five perioperative sites faced this exact challenge. Inconsistent terminology and a lack of CPT® alignment limited the accuracy of EHR case duration calculations, contributing to scheduling inefficiencies across sites.
After implementing IMO Core Periop, granular, CPT-aligned terminology was embedded directly into automated duration calculations. Four of five sites achieved a 21% average improvement in case duration accuracy (34% to 41%). The one site that relied on manual adjustments saw no improvement, reinforcing that structured, standardized data drives measurable OR efficiency.
Case duration inaccuracies and the ripple effect in the OR
From an outside perspective, booking surgical cases may seem straightforward. Most electronic health records (EHRs) automatically estimate case duration based on historical data tied to a procedure name or standardized code, then suggest how much OR time should be reserved. So why do scheduling inaccuracies persist?
The answer often comes down to surgical terminology that lacks granularity. For example, scheduling a “hernia repair” might be technically accurate, but is it a ventral hernia, hiatal, or inguinal? Will the procedure be open, laparoscopic, or robotic? In this case, and so many others, technique, anatomy, and technology all matter, so when those details aren’t captured, schedulers are left guessing.
The result is a familiar ripple effect that leaves unused OR blocks on one end, unplanned overruns on the other, along with delayed starts, staff frustration, and mounting costs. Leveraging a robust surgical dictionary that reflects the true complexity of modern surgery allows organizations to schedule with confidence and reclaim valuable OR time.
How documentation gaps follow the patient downstream
Even when case timing is accurate, documentation gaps can quietly undo the gains made on the scheduling side. Two of the most common (and costly) examples are missing laterality and unclear site-of-care designation.
Site of care
As the Centers for Medicare & Medicaid Services (CMS) phases out Medicare’s Inpatient Only (IPO) List, the distinction between inpatient, outpatient, and ambulatory surgical center (ASC) procedures is becoming less rigid – and more scrutinized. Commercial payers are likely to follow a similar path.
Historically, the IPO List provided a clear distinction: certain procedures were reimbursed only when performed in a hospital inpatient setting. The list’s retirement introduces greater flexibility, but also shifts accountability to providers who must now ensure site-of-care decisions align with payer-specific rules at the time of scheduling.
Without that clarity and level of detail, organizations face increased risk of:
- Claims denied if a commercial payer determines the procedure should have been performed in a lower-cost setting
- Delays caused by missing or insufficient clinical justification for inpatient care
- Time-consuming resubmissions and appeals that tie up revenue cycle teams
[ SITE OF CARE ]
A large hospital system in the Midwest, with 12 hospitals and 90+ clinics, was experiencing inpatient-only denials and significant write-offs tied to site-of-care misalignment. In the year prior to partnering with IMO Health, the organization recorded 205 IPO denials, resulting in approximately $5.1M in write-offs.
To address the issue, the health system implemented IMO Core Periop to ensure CPT codes were aligned to the appropriate setting before claims were submitted.
The impact: IPO denials dropped 57%, avoiding $2.1M in write-offs and reclaiming $3M in revenue.
Denial value:
Laterality
In actual surgery, as in surgical documentation, recognizing laterality is not optional. Right versus left can determine how a procedure is coded, reimbursed, and audited. Yet laterality is still frequently omitted or left unspecified in procedural documentation, particularly when clinicians rely on shorthand or generic terms during ordering and charge capture.
When laterality is missing, the burden shifts downstream. Coders must manually intervene to review the chart, query clinicians, and correct claims before submission or after a denial occurs. For large health systems, these gaps can generate hundreds of charge review edits each week, wasting time that could otherwise be spent on higher-value work.
These errors, however, are not the result of carelessness. They stem from documentation workflows that don’t reliably prompt for required clinical detail. Without structured terminology and real-time validation, it’s easy for laterality to be assumed rather than explicitly recorded.
[ LATERALITY ]
Reducing laterality errors saves $500K per day
A large hospital system in the Midwest faced significant revenue risk due to missing laterality (right/left/bilateral) modifiers on CPT codes. These omissions resulted in 650+ weekly charge review edits, requiring frequent manual coder intervention and delaying clean claims.
The organization partnered with IMO Health to curate grouper content for 2,100+ CPT codes and implemented real-time coding alerts that prompted clinicians to add required laterality modifiers at the point of post-procedural charge capture.
With IMO Core Periop, clinicians are prompted to add important laterality modifiers in EHR workflows with CPT codes.
The impact:
Within three months of implementation, laterality errors were reduced by 80%, and the organization eliminated more than $500K per day in claim edits tied to missing right and left modifiers. This saved coders 20 hours per week (approximately 1,040 hours annually), allowing them to focus on higher-value work.
Clinical terminology as the common denominator
One could easily view scheduling inefficiencies, laterality errors, and site-of-care denials as separate problems. But in reality, they all stem from the same source – incomplete or imprecise surgical terminology. When this foundational tool isn’t kept current or sufficiently granular amid evolving code sets and payer rules, everything built on it becomes fragile and unreliable.
A robust, continuously updated surgical dictionary is the bridge that connects clinical intent to operational execution. It enables:
- Precise and consistent definitions for procedures and reliable historical data
- Accurate case duration estimates by capturing procedural nuance
- Workflow-level safeguards, such as prompts that ensure required details like laterality are documented
- Clear identification of inpatient-only, ASC-covered, and excluded procedures
- Early error detection, before claims are submitted or OR time is wasted
As site-of-care decisions grow more complex and payer rules continue to evolve, the room for ambiguity in documentation shrinks. Grounding OR scheduling, documentation, and revenue cycle workflows in granular, dependable clinical terminology helps organizations get it right the first time – reducing scheduling errors and rework, preventing denials, and protecting both time and revenue.
Learn how IMO Health helps organizations streamline surgical workflows, reduce rework, and protect revenue. Schedule a demo today at imohealth.com/schedule-a-demo.
1Rothstein D and Raval M. Operating room efficiency. Seminars in Pediatric Surgery, Volume 27, Issue 2, 2018. Accessed via: https://www.sciencedirect.com/science/article/abs/pii/S1055858618300040.
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