Accurate clinical documentation is essential for determining the necessity of repeat colonoscopies, which are beneficial for certain patients but may be inappropriate for others, potentially leading to unnecessary healthcare costs and risks. Key factors such as complete patient history and clear communication between endoscopists and primary care physicians are crucial to avoid inappropriate recommendations and ensure proper reimbursement. The document emphasizes the importance of thorough reporting to support clinical decisions and enhance patient outcomes.

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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

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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 follow-up
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,
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