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Dictations and Coding in Oral and Maxillofacial Surgery
Download Ebook Dictations and Coding in Oral and Maxillofacial Surgery
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Review
"Jonathon Jundt is a remarkable surgeon who recognizes problems or inefficiencies in the practice of our specialty and seeks solutions. His collection of operative notes featuring many common procedures performed within the scope of oral and maxillofacial surgery combined with coding pearls from expert medical coder Terri Bradley provides essential and useful information to all practicing surgeons and not just residents in training...I believe this should become part of the required curriculum for all oral and maxillofacial surgery residents in training."Â Mark E.Wong, DDS, FACSProfessor and Bernard and Gloria P. Katz Chairman of Oral and Maxillofacial Surgery Director of Residency TrainingUniversity of Texas Health Science Center at Houston
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From the Author
Why did you write this book on dictations and coding in oral and maxillofacial surgery?The dictated operative note is essential for the practice of oral and maxillofacial surgery. Unfortunately, the evidence indicates that the quality of dictated operative reports is poor. Important information is often omitted, In support of this was one study which showed that only 46% of items deemed important in the operative dictation were actually present in these documents (Edhemovic). This book was written to help readers dictate high quality operative notes.Why do we have so much difficulty in this area?Surveys have shown that few residency programs offer formal instruction on the content, structure, or importance of the operative report. Thus, residents leave their training programs to enter practice feeling inadequately prepared in this critical area.Why is there a relative lack of training in operative note documentation?In my conversations with program directors, I have learned that operative note documentation is an educational priority. The challenge for program directors is how to incorporate this education into the residency curriculum. By the time residents graduate, they must acquire a large body of knowledge and master many skills. It can be difficult to find time during conferences and didactics for instruction in operative note documentation. Even when it takes place, the amount of time devoted to it may not allow residents to become comfortable and confident.What can happen if residents leave their training inadequately prepared to dictate clear and complete operative notes?Knowledge gaps in this area have important consequences for practitioners. The operative dictation is an important medico-legal document, and therefore it must be clear and complete.Among the other consequences is reduced reimbursement or even denied claims for services provided when notes lack adequate descriptions and appropriate terminology. In one study of operative notes completed by residents, that authors wrote that nearly 30% of charges "would have been missed, delayed, or denied if the resident-dictated note was used to justify charges." (Novitsky). A more recent study evaluating the accuracy and completeness of coding in oral and maxillofacial surgery found that a "large proportion of operations were not assigned all the relevant codes." The authors concluded that "even small errors can have huge financial repercussions." (Khurram)Most surgeons don't realize the importance of properly dictating and coding an operative report until after residency when they've performed a substantial amount work and fail to receive reimbursement. With increasing scrutiny of medical records by payers, it is more important than ever for the operative note to succinctly and clearly describe what was done to justify the codes that are submitted and maximize the chances of full reimbursement. How can oral and maxillofacial surgeons use this resource to improve patient care and maximize reimbursement?Dictations and Coding in Oral and Maxillofacial Surgery was developed to be a resource for residents, surgeons, office staff, and billing and coding specialists to enhance coding and operative dictation accuracy.Numerous procedures are found within each of the book's ten sections, and include indications, complications, key steps and a coded operative dictation template for individual procedures. Complete operative reports have been reviewed by surgeons and professional coders for accuracy and content.Â
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Product details
Paperback: 215 pages
Publisher: Md2B; 1 edition (June 25, 2017)
Language: English
ISBN-10: 1937978060
ISBN-13: 978-1937978068
Product Dimensions:
8.2 x 0.5 x 10.8 inches
Shipping Weight: 1.9 pounds
Average Customer Review:
5.0 out of 5 stars
2 customer reviews
Amazon Best Sellers Rank:
#282,447 in Books (See Top 100 in Books)
Badass book.
Great book, very detailed and precise. Has made my dictations easy and has streamlined the process.
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