How Accurate Clinical Documentation Is Crucial for Repeat Colonoscopy

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How Accurate Clinical Documentation Is Crucial For Repeat Colonoscopy

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The recommendation for repeat colonoscopy and its effectiveness on patient health has always remained a topic of debate among healthcare experts. However, a recent study reveals that repeat colonoscopies within ten years provide little benefit to patients who had adequate examinations and found no polyps, whereas they are beneficial to those patients whose baseline examination was compromised. Though the study found that repeat colonoscopy is beneficial for certain conditions, it is still up to the physicians to decide whether it is appropriate or not and here documentation plays a crucial part. The colonoscopy reports communicate the findings to the referring physician and clinicians and stand as a frame of reference for subsequent examinations and medical care. Let’s see how documentation is crucial for repeat procedures.

Enhance the Quality of Procedures Know about what has been done earlier. The physicians should be aware about the demographic information, patient history, sedation procedure, procedure quality, lesion

identification/removal

and

procedure

interpretation.

With

clinical

documentation, physicians will get the details of procedure indication, medication name and dose, preparation adequacy, extent of examination, polyp size and location, if present. The reports that have carefully documented essential elements of the procedure will help endoscopists have the detailed information necessary to determine whether the patient requires surgery, check whether the patient suffered a complication or has the chance to develop a cancer, or whether the patient will have to return for a subsequent procedure for improved outcome. Post-procedure recommendations such as the timing of repeat endoscopic procedures should be clearly documented as well to avoid exposing patients to additional risk.

Avoid Inappropriate Use A 2013 study published in JAMA Internal Medicine found older Americans may be getting inappropriate colonoscopies which increased the risk of adverse effects and caused Medicare unnecessary cost of around $500 million each year. So, it is very

www.medicaltranscriptionservicecompany.com important to ensure that repeat colonoscopies are recommended appropriately. Two major anomalies that may lead to the inappropriate use of repeat colonoscopies are:



Incomplete Documentation – A 2002 study by a group of American researchers found incomplete documentation of examination extent or preparation adequacy can lead to unnecessary repetition of examination at short intervals in future, if the symptoms persist. So, if the documentation of the first endoscopic procedure is not complete, it may mislead endoscopists and they may advise repeat procedures unnecessarily.



Communication Gap between Endoscopists and PCPs – The endoscopists’

recommendations

for

repeat

procedures

should

be

communicated to and documented in primary care physicians’ (PCPs) records, and should adhere to the American Society for GI Endoscopy (ASGE) reporting guidelines. PCPs should not rely solely on the endoscopist’s followup recommendation unless there is complete and transparent communication between them. They should also make sure that there is complete information within the records and that the information justifies the endoscopist’s recommendations.

On the whole, physicians should strive to prepare a medical report that fully documents all the details of the examination and thus avoid inappropriate use of repeat procedures.

Getting Proper Reimbursement The 2002 study mentioned earlier says that incomplete documentation of indication can result in unnecessary delays and efforts in acquiring reimbursement from payers. If there is no indication documented to justify the need for repeating the procedures, payers may consider the procedure inappropriate (depending on the policy) and will deny payment. Even if you want to appeal the denial, you should have clear and complete documentation of previous endoscopic procedures and repeated procedures.

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About The Author MTS Transcription Services (MTS) is a US-based medical transcription company, committed to provide HIPAA compliant medical transcription services for healthcare providers. We offer quality medical transcription outsourcing services to hospitals, clinics and healthcare facilities of all major specialties including pediatrics, pathology, orthopedics, cardiology and more.