Wiki United Healthcare documentation issue on op notes

We've been getting pushback from UHC and Optum on our op notes. They are stating they cannot verify the surgeries we are billing were documented. I have screen shot a sample of a note below. There's the pre/post op diagnosis and the operation synopsis listed of the exact graft we billed. They are stating since the type of graft and sq cm are not repeated within the operation body, they won't pay the claim. Does anyone have a resource or a reference that would allow me to dispute this?

In the meantime, I have having the physicians repeat the information in the body, but I don't believe there is a requirement on this particular issue.

They are getting you on a technicality here, and in my opinion this is in bad faith since there information is there. However, accepted coding standards are that the code used must be supported by the description in the body of the operative report and not the title of the procedure. Here's an article from the AAPC site that mentions this:


I'm not sure there's much you can do to fight this. You could appeal or take it up with a network rep making the case that these services were medically necessary, provided in good faith to the patient, and that you're aware that this should have been documented better but that your provider shouldn't be penalized for such a minor discrepancy in documentation and that you would like to request that this be paid as an exception. It may or may not work. Best practice is what you're doing now - making sure the providers put everything in the body of the note.

Thanks for the link - I have forwarded this to my providers.

madcomic2000 said:

Thanks for the link - I have forwarded this to my providers.

Click to expand...

I do totally agree with Thomas' answer, but I do have a different take on it as well. While it is best to have it on the body of the op note, it's not missing either. I agree with Thomas that this is a "Bad Faith" decision by UHC. To me it seems like they are looking for a reason to deny the claim rather than process the claim correctly. I have seen UHC also deny payment on a surgical procedure even though the surgical procedure was not only documented, but documented very well. I have coded/reviewed op notes from many orthopedic providers in Utah, Arizona, Washington and Alaska. I have seen it all from very bad documentation to op notes that I would say are picture perfect. So when I see UHC deny a claim stating the procedure is not documented when its documented very well, it makes me wonder. Be prepared, you could see denials on procedures that are actually documented very well.

These kinds of denials are rampant within UHC/Optum. I've had numerous claims denied for the same reason and the majority of my claims deny asking for medical records so they are sent to Optum for pre-pay review. It feels like harassment and delay of payment tactics. Sadly, our practice is reconstructive breast surgery and these patients are undergoing treatment - the situation provides extra stress for someone trying to heal from surgery. I'm wondering if it is time for someone to file suit so we can determine if our claims are being reviewed by medical providers in our specialty or at the very least someone who has the knowledge base to be able to extract an operative report.