Surgery scheduling is hard, but does not have to be. Approximately 20% of surgeries are cancelled due to poor pre-op planning because this involves many moving parts and stakeholders. Here are a few helpful guides to streamline the surgical coordination process and project manage each surgery to completion. You can use this surgery checklist as a status tracker for your surgeries (feel free to modify it to suit your needs)
Who is involved in the surgery scheduling process
Here are the parties / stakeholders that need full participation for successful surgical coordination.
- The patient
- the surgery scheduler from your practice
- the primary care physician
- laboratory vendors
- insurance / payers
- surgery schedulers from the hospital/ambulatory surgery center (ASC) your surgeon is operating in
- the medical billing department on your side
- the medical billing department on the hospital/ASC side
Surgery scheduling process and workflow
It’s not really rocket science but yes, it does have quite a few moving parts. Fundamentally, here are the various steps involved in a surgery scheduling (preoperative and perioperative) workflow.
Preparation and planning for a surgery
- Patient is identified by one of your providers as a surgery candidate.
- Make sure that the surgeon hands over a booking sheet / form that includes the patient details, desired location of surgery, date/urgency of the surgery, CPT code of the surgery to be performed and the diagnosis code along with notes as well. You are going to need to send these info over to the hospital or surgery center where the surgeon will perform the surgery. You are going to need the CPT for prior authorization / pre-cert as well. Here’s a sample surgery booking form to use (you can also convert this into a word document to hand over to your surgeons).
- The patient is then taken to a sub waiting room for a discussion with the surgery scheduler or is called on the phone by a centrally located surgery coordinator.
- You can take this opportunity to administer surgery counseling as well (if you are staffed with counsellors). Do not confuse surgery counseling with surgery scheduling. Surgery counseling is a separate topic altogether.
- The surgery scheduler has a discussion with the patient about the surgery, what to expect, how to prepare for it, what the next steps are.
- The scheduler sets a tentative date for the surgery if it is an URGENT (1 week) surgery. For STAT (Today) surgeries, you would usually bypass this step because patient care is of utmost importance (pre-cert can also be done retroactively).
- The surgery scheduler also explains the patient responsibility aspects of the surgery costs. This is where the surgery scheduler lets the patient know that they need the patient responsibility portion paid up front for us to book the surgery.
- The surgery scheduler lets the patient know that any overpaid amounts after account balance reconciliation would be refunded to the patient.
Incorporate the above steps in your surgery scheduling process and see the difference it makes. Your mileage may vary, but essentially, the process itself does not need to change much.
Getting appropriate signatures from the patient
- The surgery scheduler then has the patient sign the medical records release consent form, the surgery consent form. The medical records release consent form is required so that the coordinator can get the surgical clearance form from the PCP along with the entire history/continuity of care document of the patient.
- The patient is supposed to get the medical clearances from their PCP. However, in our experience, patients cannot be trusted to get these done by themselves. Based on our recommendation, the surgery scheduler needs to start getting the appropriate medical clearances. This allows the scheduler to be in control of the surgery a bit more than if the patient is given the responsibility to get the clearances done.
- If the surgery coordinator does not want to handle the pre surgery clearances, at that point, they need to hand over the Pre‐Surgical Medical Clearance form to the patient and instruct the patient to take the same to their primary care provider.
Keep in mind that in a surgery scheduling process, this is crucial. While it doesn’t sound important in the beginning, when you are running around trying to get medical records, this step becomes crucial (else you have to ask the patient to come back into the clinic).
Getting history and physical from the patient’s provider, pre-admission testing (PAT)
- The surgical coordinator informs the patient that their PCP / physician needs to complete a full History & Physical Clearance Form and that should be within 30 days of the surgery date.
- In general, if the surgeon has asked for MAC (Monitored Anesthesia Care), then the patient is advised that the EKG should be within 1 year of the patient’s scheduled surgery date. Meanwhile, if the surgeon asked for General Anesthesia, then the EKG needs to be within 30 days of the patient’s scheduled surgery date.
- The surgery coordinator also needs to inform the patient that based on whether the patient has other medical issues, additional testing may be required (e.g. some lab work, chest x‐ray etc.). This is usually at the discretion of the PCP or doctor providing medical clearance in order to medically clear the patient for surgery. Keep in mind that many a time, the surgeon can also complete the history and physical of the patient.
- It is ALWAYS in your surgeon’s best interests to get the patient’s medical AND surgical history from their primary care provider. This avoids situations of “conflict of interest”.
- In case the surgery coordinator is willing to take over the responsibility of getting medical clearances for the patient, at this point, while the patient is still in the waiting room, the surgical coordinator calls the PCP office, going through the “provider’s line” to set up an appointment for the patient.
- While they are setting up an appointment date/time with the PCP for the patient, the coordinator also sends a fax with the pre-surgery clearance forms along with the medical records release consent form to the primary care doctor office.
In a surgery scheduling process, getting the PAT is probably the one that always causes delays. We have noticed that when this task is left up to the patient, surgeries almost never go “on time”.
Setting up pre-op, surgery and post op dates
- Based on the surgical clearance date/time obtained, the coordinator can then pick a date for the surgery. To be on the safe side, you should pick a surgery date at least 7 days away from the surgical clearance date.
- Having a pre-op appointment with the patient without the clearance forms being obtained usually does not make any sense. It is advisable to set up a pre-op appointment after the clearance appt date. There are also specific cases that one needs to take care of (e.g certain pre-op procedures/injections need to be administered and the surgery needs to be done within X days of the pre-op appt. Typically a 5 day period is a good target to set between the pre-op and the surgery date. For post op appointments, you should target the next day, next week, next month.
- The surgery scheduler then schedules the pre and post operative surgery dates. They explain to the patient that these are tentative dates and that these might change based on the actual surgery date.
- The surgery scheduler then also hands patients informational leaflets about the surgery, what to expect etc (i.e patient education handouts)
- This is also the right time to communicate a tentative surgery date to the hospital or the surgery center – by this time you are somewhat sure about the PAT date.
Pre-cert and prior authorizations
- After the patient leaves, the surgery scheduler starts getting the needed pre-certification from the payer. Note the differences between a pre-cert and a prior auth.
- If it is a non urgent or elective surgery, then you need to send a precertification request to the payer first. The payer will let you know whether the requested procedure is covered or not. This is similar to an eligibility request in that you do not need to submit any medical documentation.
- If the payer responds to the precertification request with a denial (i.e. surgery is not covered by the patient’s plan), then the surgery coordinator needs to discuss with the patient and the surgeon about next steps.
- If the payer responds with an approval, the next step is to submit the patient’s medical records and the surgeon’s documentation to prove why a particular procedure was chosen. Only after you get a prior authorization, are you truly ready for the surgery.
- Meanwhile, if it is an emergency procedure, the surgical coordinator can skip the pre-certification process and try to get the prior authorization retroactively after the surgery. Various payers stipulate that such prior authorizations should be obtained between 24 and 72 hours after admission.
Staying in contact with the patient
- Our recommendation is for the surgeon’s office to stay in close contact with the patient to remind them of the clearance appointment they have with their PCP. This ensures that the clearance / PAT happens on time.
- On the date of clearance appt, the surgery coordinator should call the PCP office to obtain the clearance and the patient history / continuity of care document. This should include the entire medication list as well. Here’s a sample medication list form that you can ask your patients to carry with them to their PAT.
- Keep in mind that the clearances for history and physical should be received at least a week before the surgery depending on the patient’s health conditions.
- Once the surgical clearance form is received from the PCP office, the surgeon’s office (your practice e.g.) needs to go over the history with the patient as a checklist. Often patients do not understand what is a surgery and what is not (a classic example is a C section). Here’s a checklist sample.
- The surgery scheduler also needs to dig deeper into patients’ medications and specifically ask for any over the counter “herbal medication” they might be taking. Most patients do not think that herbal medication can interfere with anything related to their surgeries – but they might interfere with anesthesia.
- Based on the age, medical history of the patient, sometimes, diagnostic testing might be required. This is almost never a standard list, but these are prerequisites of that particular surgery – and these need to be done, results obtained at least a week before the surgery. There’s a lot more information available here on Medscape.
- Patient education has to be enforced multiple times as patients are, understandably, anxious and might delay their care / surgery.
- The surgery scheduler should be advising the patient on preoperative fasting, medications, anesthesia, and postoperative care that the patient should expect. The reasons for fasting should be explained to the patient repeatedly – this is where most of our surgery cancellations occur. Patients simply do not understand that not fasting opens them up to chances of vomiting, nausea post operatively.
While technically you don’t need a pre-op in your surgery scheduling process/workflow, you almost always should have one to ensure that you get another chance to counsel the patient, prepare them for the surgery, get all loose ends tied up.
Being true partners to your surgery center/hospital
- Your surgery center partners have significant investments in equipment and need your help in achieving their targets as well. Understand that clearly. You cannot promise 30 patients, get a block time for your surgeon and show up with 10 patients.
- Throughout this time, the surgery scheduler is / should be coordinating with the surgery center or hospital about the block of time and number of patients that they should be expecting.
- Until all the prerequisite steps have been met, the surgery cannot be confirmed from your practice’s side and unless you confirm the surgeries from your side, the surgical center runs the risk of losing revenues (their investments are significantly higher than yours).
- Make sure that you do not submit one piece of information at a time. Your surgery partner will expect an entire surgery packet from you – send the entire packet together, in one shot and always keep your surgery partner up to date on the latest status of the patient.
- Any laboratory/diagnostic test results and all medical clearance documentation should be submitted to the surgery department beforehand. This helps to avoid repeating procedures and therefore saving time + money.
- The better your surgery no-show rates are, the more advantageous block times your surgeons get. Over time, we have noticed that some ASCs end up dropping some associated surgical partners because of the no show and cancellation rates.
- The surgery scheduler should be following up with and remaining in touch constantly with patients so they don’t cancel or back out. Bake this into your surgery scheduling process as an integral step.
No shows and cancellations – part of the surgery scheduling process
Despite how good your surgery scheduling process is, you are going to have noshows and cancellations. While this is bad for your practice’s financial health, it is even worse for the patients that actually do need surgery based on their diagnoses. If not for your own practice, ensuring noshows and cancelled surgeries are re-booked, helps your patients as well.
- No shows and cancellations happen – it’s part of the process. Most surgery coordinators forget to follow up with these patients and bring them back to the table. You should treat such candidates as any other no-show / cancelled patient appointments. A gentle nudge / reminder usually gets the job done.
- Patients that do not show up for the pre-operative appointments will most likely not show up for their surgeries either – following up with patients to ensure that they do show up for their pre-operative appointment is very important.
- Following up with a patient after the day of surgery to ensure no complications occurred is CRUCIAL. The surgery scheduler needs to make that part of their workflow for the patient as well.
- Usually, the surgery center does provide all post operative care instructions, however, care instructions specific to your speciality should be followed through by your team. This could include the medications the patient can and cannot take, the correct way to take eye medications, eye and wound care, the appropriate emergency contact information that the patient needs.
- The surgery scheduler should also ensure that the patient does show up for their post-operative appointment the next day after the surgery.
- When the patient shows up for their post-op appointment, the coordinator should also ensure that the patient has follow up appointments (recommended) one week after surgery, one month after surgery, and three months after the patient’s surgery.
- The day after the surgery is typically the best time for the surgery scheduler or the front desk staff to follow up with a patient satisfaction survey.
- Following up and following through this entire process with clear indicators of dependencies, full transparency between the patient, surgery scheduler on both your practice’s side and the hospital/ASC’s side, the surgeon is needed to ensure closing the loop on Surgery scheduling and successful surgeries.
COVID – special considerations for your surgery scheduling process
These days, in addition to the regular steps in your workflow, you also have to manage COVID related tests. Keep in mind that most surgical centers will ask for both a surgeon and patient COVID test results.
As a general practice, you should have a list of COVID testing centers that each one of your surgical partners approve of. A COVID test result will be valid for 48 hours, so you should plan on having your patient take the test 2 days (max) before the surgery date.
We have noticed that surgeons are fast tracked at most of these COVID testing centers. You should advise your surgeon accordingly (even if they are aware of the same).
Most COVID testing centers fax the results back to the surgical centers. However, considering how things are working these days, it is in your best interest to ensure that the results are faxed to you as well. Follow up with the center to obtain the fax – mostly because this puts you more in control of the surgery appointment.
Your goal is to ensure that you have all the necessary paperwork so your surgeon can perform the surgery during the block of time they are allocated. Do everything you can, to ensure that.
Post surgery workflow
On the day of the surgery, ensure that you also deliver a surgery package to your surgeon (just in case the surgery center / hospital is missing any paperwork – we have seen that happen a few times). After the surgery, ensure that your surgeon hands you the operating note.
The op note is what you are going to need for billing. Ensure that it has enough information and highest levels of specificity for you to be reimbursed in full without any denials. Make sure that
- The note contains both the pre-op and post-op diagnoses (just in case it has changed).
- The note contains CPT terminology as much as possible but not the CPT code itself (sometimes, this clashes with billing codes)
- The note has at least a few sentences about “Indications for Surgery” that your coders can use
- The note has “Complexity” section that buttresses your claim for payment
- Finally, the note, of course, has to have the description of the surgery