To some people, the term minor connotes something unimportant or inconsequential. From this connotation, it’s a short step to a brief chart note that hardly supports the reasons for a minor procedure. But minor surgery is not trivial, and the chart documentation must support it by including what was done and why. Without adequate notes, third-party payers may rescind payment for the service. This month’s column answers some important questions about minor surgery documentation.

Q. What defines a minor procedure?

A. The Centers for Medicare and Medicaid Services (CMS) differentiates between minor and major surgery based on the number of days in the global surgery package.¹ According to CMS, if a procedure has a global period of 0 or 10 days, it is defined as a minor surgical procedure. If a procedure has a 90-day global period, it is a major surgery. Without this objective definition, the terms minor and major are subjective and open to interpretation. For some examples, see Table 1.

Q. What should be included in the medical record for a minor procedure?

A. Table 2 identifies the elements of an operative report for a minor procedure. Some elements are standard, while others are extraordinary, such as added notes for unlisted CPT codes. A template is useful to speed charting. This operative report should not be embedded in notes for the concurrent office visit but should be separate and distinct.

Most of these elements are self-explanatory, but a few are not. There should be 1 or 2 sentences that explain the indication(s) for the procedure, including patient complaints, and the anticipated outcome. If this procedure is related to an earlier procedure, such as a staged operation or to remedy a surgical complication, that should be described. The description of a procedure is improved by measurements, such as the size of a lesion or excision. When a medication is administered, identify it along with concentration, lot number, expiration, dose, and any wastage. For 2023, CMS expressed interest in tracking discarded medications more closely using modifiers JW and JZ.² For wastage less than 1 unit, state, “any residual medication less than 1 unit was discarded.”³

Minor procedures with identified risk factors warrant mention of any comorbidity, surgical challenge, special considerations, and mitigating conditions that add complexity to the minor procedure. When a minor procedure is performed that does not have a specific CPT code, then additional description of the duration, intensity, and comparable procedures is required for the reviewer to make their determination of payment.

Q. Is additional information required if the minor procedure involves use of a laser?

A. When a laser is used, some additional elements should be included in the operative report, including the following:

• Laser type, make, model, wavelength
• Laser lens
• Power or energy
• Size and number of applications (spots)
• Duration of laser
• Placement of spots

A sample operative report for laser cases⁴ that includes these elements is available at https://bit.ly/40znXBw .

Q. Should consent be documented as part of the operative report for minor procedures?

A. While not strictly part of the operative report, the medical record should note that risks and benefits of the procedure, as well as alternatives to the procedure, were explained to the patient, any questions answered, and that the patient gave informed consent to proceed. For procedures that are considered risky, a written consent form that includes the patient’s signature may be useful. Otherwise, where there is a negligible risk, a short note in the plan should suffice. Check with your medical malpractice carrier if you have questions about consents.

In our work with clients, brevity can be problematic if Medicare, Medicaid, or another third-party payer seeks to recover payment for a minor procedure that hasn’t adequately been documented in the medical record. RP

REFERENCES

1. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual, Chapter 12 §40.1C. Accessed March 31, 2023. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
2. Centers for Medicare and Medicaid Services. Discarded Drugs and Biologicals — JW Modifier and JZ Modifier Policy Frequently Asked Questions. Accessed March 31, 2023. https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/jw-modifier-faqs.pdf
3. American Academy of Ophthalmology. Checklist: Intravitreal Injections Documentation and Coding Guidelines. Accessed March 31, 2023. https://www.aao.org/Assets/9275c872-9d4c-4405-a4cf-5d1c38ec0912/637956921006100000/intravitreal-injections-cl-pdf?inline=1
4. Corcoran Consulting Group. Laser operative report. Accessed March 31, 2023. https://www.corcoranccg.com/products/forms/operative-report-forms/laser-operative-report/