Challenges of Using Mobile Transcription Apps in Healthcare

22-January-2015 Rajeev Rajagopal Healthcare News

Healthcare providers are relying on technology to speed up their clinical documentation process and thereby address the increasing healthcare demands. Mobile transcription apps are one such technological development. The advantages of using such apps are that

Clinicians can use them at any time
You don’t require much technical training to use them
Improved documentation times
Clinician time savings

However, the accuracy of documentation is still doubtful even though several technological advancements are evolving.

Mobile transcription apps come under speech recognition technology in which the healthcare provider uploads the audio recordings into the apps which process the audio data into relevant documentation. The major challenges about doing ‘mobile-based’ transcription are:

Certain speech recognition apps may have difficulty in understanding specific accents. As a result, the report may have wrong words and incorrect data will be sent to clinicians, and the diagnosis and treatment may go wrong. Keywords may be omitted, and that could alter the meaning of a sentence (for example, ‘yes’ or ‘no’). Sometimes, centimeters are replaced with millimeter, which can result in adverse effects, especially in the case of medication dosage.
The apps may not have the ability to recognize grammatical errors. Such kind of errors can cause comprehension issues with reports.

However, innovative technologies can make transcription applications smarter and more interpretive to overcome these challenges. A system of user profiling is now available which can learn the style and voice of a particular healthcare professional. This system learns to adapt to individual users according to their habits or preferences fed back into a profile established earlier. Advanced features including vocabularies sorted by physician specialty and regional accent wizards can also be built into a profile. However, even with the most advanced transcription apps, clinicians can still encounter the following challenges.

A noisy environment can cause physicians’ spoken words to get mixed with other noises so that the apps can’t recognize what is actually said and generate wrong data. Sometimes, the physician’s voice style may change due to cold or some other health issues. This will also hinder the app from recognizing the correct words.
Physicians can make mistakes that may not be recognized by the apps since they simply transcribe what is said in the dictation. For example, the physician may say ‘wound in the left arm’ for ‘wound in the right arm’ inadvertently and the app will record it as ‘wound in the left arm’, which is wrong. Sometimes, clinicians may imply something more than what they say in words and the app is not capable of interpreting that information.

This is why human intervention is important to ensure the accuracy of transcribed documentation.

Importance of Healthcare Documentation Specialists

A draft of the transcribed documents can be sent to healthcare documentation specialists along with the voice files so that they can listen to them and correct the errors. Healthcare documentation specialists comprising medical editors and QA reviewers can ensure accuracy in the following ways.

They can proofread the document to check for inconsistencies, omissions and grammatical mistakes.
As they are well-versed in medical metrics, they know what drugs work for what indication, the most appropriate context for homonyms (for example, mucous/mucus), age-relative ailments and common laboratory values so that they can easily understand what is actually meant by the clinician.
They also interact with physicians to correct doubtful terms and expressions, and use various technologies and resources to produce complete and accurate reports.

Collaborative Depression Care for Pregnant Women, What’s the Role of Documentation?

15-January-2015 Julie Clements Obstetrics & Gynecology Transcription

Untreated depression during pregnancy can lead to poor nutrition, drinking, smoking, and suicidal behavior in mothers and also result in premature birth of the baby, low birth weight and developmental problems. A study published in Obstetrics & Gynecology (June 2014 issue), the official Publication of the American College of Obstetricians and Gynecologists (ACOG), says evidence-based collaborative depression care intervention at obstetrics and gynecology clinics is feasible, significantly more effective than usual care in enhancing the quality of mental healthcare, depressive and functional outcomes and improving the satisfaction with depression care and can be provided at modest cost. However, documentation plays a major role in turning this into a successful care model. Before exploring this, let’s take a brief look at the collaborative care model.

Collaborative Care Model – An Overview

According to the study, collaborative depression care model comprises a team of mental health specialists who aid site clinicians in patient depression management. Allied health specialists including nurse care managers or social workers serve as depression care managers, whose jobs include providing evidence-based psychotherapy and tracking patient treatment responses, medications, and compliance. The key components of collaborative care models are team management, tracking systems, and weekly structured case reviews with psychiatrist, depression care manager, and site clinician. In this model, communication influences the level of collaboration that exists in relationships among the team members.

Proper Documentation and Enhanced Communication

Collaborative arrangements require communication to build trust and mutual respect and if you want to establish a good relationship with the psychiatrist, depression care manager and site clinician, an appropriate and comprehensive communication plan is inevitable. Standardized clinical documentation can serve as the best communication plan. Clear and consistent records of consultations, psychiatric interviews, information provided to the woman, indications of messages they had understood, patients’ understanding of their risks, and their choices can significantly improve the communication flow between clinicians and those who are involved in the woman’s care.

Since the key decisions are made on the joint accountability of collaborating professionals, the details of all referrals, consultations and decisions should be documented well to avoid any blurring of responsibilities. These records will help them to make sure that nothing is going wrong. It is also required to document whether the patient is following the recommendations of maternity care professionals and what her response is so that the professionals can identify opportunities for improvement or confirm whether their treatment methods are effective. Conflicting opinions may come up regarding the woman’s care due to the complex interactions in the collaborative care model. It is possible to reduce the chance for such issues by properly documenting histories and care plans.

Electronic Health Records (EHRs) system can be considered an effective documentation system for the collaborative care model since it allows quick sharing of documents among collaborating professionals and supports more streamlined care for pregnant women. However, the major risk with this system is that physicians may copy and paste data to save their time and there is a greater chance for making errors while doing this more frequently. A small error that occurs in one document will be propagated quickly to other documents and reach other collaborating professionals to provide them with wrong information. Transcribing physicians’ dictations and utilizing Discrete Reportable Transcription (DRT) technology to insert the transcribed information into appropriate EHR fields is a better option to avoid this issue.

Telemedicine and the Role of EMR Transcription

12-January-2015 Rajeev Rajagopal Medical Transcription

Telemedicine that allows physicians to see patients and communicate with them in real time is an effective solution for reducing unnecessary and expensive emergency room (ER) visits. It is a significant fact that most of the costly ER visits are for minor medical conditions that can be diagnosed and treated virtually. Remote consultation facility is not to replace the emergency department (ED) or the patient’s primary care physician office, but to treat minor medical conditions (for example, sinusitis, allergies, sports injuries) that do not require a visit to the ED or urgent care center. Before exploring the role of EMR transcription in telemedicine, let’s take a look at the significance of telemedicine in emergency care.

With videoconferencing units, telemedicine connects patients and their family members residing in remote locations to emergency physicians. Here are the major benefits of this option.

At the time of an emergency, patients need not spend time traveling long distances or pay for the traveling expenses to a doctor’s office, clinic, or hospital. They can directly communicate with the emergency department.
Supports staffs in making quick decisions regarding emergency stabilization and transport.
Improved communication between referring and accepting emergency personnel so that ER physicians who are experienced in trauma and other critical situations can be immediately involved in the care of patients.

Telemedicine and EMR Transcription

Telemedicine or remote consultation details have to be documented accurately. Documentation of clinically relevant aspects of the patient encounter facilitates improved communication with other providers, and coordination of follow-up care. An integrated electronic medical record (EMR) system can help in ensuring effective documentation of all clinical reports.

With standard point-and-click templates, physicians can enter patient health data into the computer by clicking on the appropriate clinical terms from the available choices and the ED records will be readily available throughout the remote care. Quick and easy access to ED records enhances the quality of care and cuts down the operational costs at the same time. Records of e-visit kept in electronic format can be sent to the specialists (if necessary) at distant places quickly as well. However, the electronic record system has the following challenges.

The templates and drop-down menus may not be able to contain all the necessary information regarding the patient encounter or patient care. Physicians may want to record the entire clinical narrative since that’s where they document their medical decision making.
In telemedicine, the practice of engaging the patients fully, listening to their problems carefully and closely watching their body language is quite essential for proper diagnosis and creating trust. When physicians are involved in finding the right templates and relevant EMR fields, they won’t get enough time for that. The speech recognition system integrated with EMR may not be accurate all the time as the system can’t recognize spelling and grammar.
While documenting necessary details, physicians may frequently copy-paste data without checking the whole data in an effort to save valuable time. If there is a minor mistake in the data, this will be reflected in all the records and make the entire system erratic.

A combined approach using both EMR and transcription is thus relevant in telemedicine. In this approach, physicians can dictate their findings and other information related to emergency care which is transcribed by trained transcriptionists in a medical transcription company. The completed transcripts will be sent to the provider’s EMR via a secure HL-7 interface.

Why Transcription of Emergency Room Reports is Challenging

08-January-2015 MTS TEAM Emergency Room Transcription

Emergency room scenarios are unpredictable, making things quite challenging for ER physicians, their staff and medical transcription service providers. This is because emergency room reports are based on variable elements and there are cases where the condition of patients keeps fluctuating and moving to various levels. Transcription needs to be handled with utmost efficiency and delivered in fast turnaround time. In fact, a pressure-resistant mindset is crucial for overcoming the challenges associated with emergency room transcription, which include the following:

There are chances that the ER doctor speaks with a strong or unfamiliar accent. This means that transcription would take longer than what is needed in a normal case. This would also happen if the physician speaks too fast or vaguely.
Only a clear recording can be transcribed within the stipulated time period. In ERs, background noises may affect the quality of the recording. If the physician is not using a microphone, it would result in a poor recording.
The specialization of ER doctors is not within a specific medical area but extends to trauma care, life-threatening conditions, advanced cardiac life support, and much more. Depending on the fluctuations of the patient’s condition, the treatment provided can vary. The transcriptionist has to be well-versed in the technical terms related to all these areas to provide accurate clinical documentation for quick decision making.

Complex dictations with considerable background noise, an inaudible speaker, unfamiliar terms, and strong accents will take about 15 minutes to transcribe. Outsourcing the task to a professional medical transcription company would be the right decision. This would ensure accurate documentation in the required turnaround time, ensuring smoother workflow, improved decision making, and quality patient care.

Physicians and EHR – How to Save their Relationship

05-January-2015 Julie Clements EHR Transcription

Physicians and EHR As the adoption of the electronic healthcare system gathers pace, healthcare providers are adopting EMR/EHR to achieve meaningful use objectives. The main benefits of electronic health records are easy sharing of patient information, improved security of protected health information (PHI) and reduced cost of care. However, physicians are finding that entering information in EHR is an arduous and time-consuming task. A report in Information Week says that the EHR is falling short of expectations, causing physician burnout, and leaving them with less leisure time. Data entry by physicians in EHR has resulted in loss of physician productivity, reduced focus on patients, and incomplete capture of information in patient records. The solution lies in getting professional assistance to deal with the demands posed by electronic documentation.

Hiring Medical Scribes or Assistants Can Help

Studies say that physicians nowadays spend, on average, eight to 12 minutes per patient to fill out the EHR. According to a 2012 survey of more than 7,000 doctors using EHR, about 45.8% displayed at least one characteristic of burnout. Moreover, when they entered information into the EHR during the patient encounter, it often happens that they pay less attention to the patient and may miss out on important nonverbal clues which could be pertinent to care.

The doctors can benefit from real-time, in-parallel documentation and relieve themselves of administrative tasks by hiring a professional assistant or medical scribe. When filling out EHR right after the exam or procedure, the physician may miss out certain activities and insights which may be quite significant. A medical scribe, a professional physician’s assistant trained in medical documentation and other tasks would efficiently perform the data entry task. The assistant would capture every billable procedure on the chart, freeing up the physician from the administrative task which would give them more time for patient care.

Medical Transcription Outsourcing for EHR Support

Another option that physicians have is medical transcription outsourcing. Medical transcription services are playing a significant role in the adoption of the electronic healthcare system. A professional medical transcription company ensures accurate, prompt, secure creation of medical records and eases EMR/ EHR adoption. The documentation provided by the company ensures that the entire patient encounter and narrative is recorded. This improves care as well as medical coding and billing. HL7 interface allows the transcription company to interface with the electronic health record system. They can even provide proofreading and editing services for the transcripts that the physician creates using speech recognition software.

Benefits of Professional Support for Electronic Documentation

Professional support for digital documentation improves the efficiency of the physician and enhances overall productivity of the practice in the following ways

Helps the physician see more patients
Results in detailed and better documentation
Reduces the time physicians spend on administrative tasks and documenting patient visits
Helps prevent physician burnout by giving them more free time
Increases practice compensation
Saves time for training to use EHR/EMR
Eliminates chances of wrong entries caused by stress
Enhanced charge capture
Increases EHR/EMR adoption rate
Improves compliance

As far as hospital productivity is concerned, it is not sensible to use a doctor to type or fill out forms. Getting professional assistance for electronic documentation allows physicians to utilize their time productively, see more patients, and ensure comprehensive care.

Women with Hematuria Facing Diagnosis and Referral Delay

01-January-2015 Rajeev Rajagopal Medical Transcription

A new study by the Vanderbilt University Medical Center reveals that women with hematuria (blood in urine) were less than half as likely as men having the same issue to be referred to an urologist for additional tests.

Hematuria is considered as the first sign of bladder cancer and the American Urological Association (AUA) recommends that every person above the age of 35 with hematuria not due to a benign cause receive an evaluation by a urology specialist, which would include a cystoscopy and imaging of the urinary tract. The study says that women with hematuria face diagnosis and referral delay, which may explain why they are diagnosed with cancer in the later stage and have higher mortality rate than men. Funded by the National Cancer Institute (a division of the National Institutes of Health), the study stresses the need for better diagnosis and treatment for women with hematuria.

The study involved the review of the records of 9,211 Medicare beneficiaries diagnosed with hematuria from January 2009 to June 2010 and found that only 17 percent of females diagnosed with hematuria by their primary care provider were referred to an urologist for a diagnostic workup within 180 days while 39 percent of men were referred for the same issue. According to one of the researchers, this data suggest misdiagnosis and treatment of hematuria in women, as urinary tract infection is one of the major reasons why they are prone to more advanced stage bladder cancer during diagnosis.

According to the study, another reason for the disparity in referrals is clinical decision-making by physicians as they know that women are less likely to have bladder cancer than men. The findings suggest that physicians need to be more vigilant and stop missing opportunities to diagnose bladder cancer earlier in women. It is necessary for physicians to find a way to risk stratify women and determine whether or not they need a diagnostic workup.

When you visit a family practice physician with the signs of hematuria, the doctor will take a complete medical history to check for the risk factors and understand more about the symptoms. A physical examination is also performed to gather other information about possible signs of bladder cancer. If the physical examination produces abnormal results, the physician will conduct screening tests (for example, urinalysis, urine cytology) or refer you to a urologist for further tests and treatment.

Electronic Documentation and the Role of Medical Transcriptionists

29-December-2014 MTS TEAM EHR Transcription

Electronic Documentation Though paper-based clinical documentation is transitioning to electronic clinical documentation, a human interface is still relevant to make the technology work optimally and that human interface already exists in the form of skilled healthcare documentation specialists as per the Association for Healthcare Documentation Integrity (AHDI). “Healthcare documentation specialist” is an umbrella term given for transcriptionists, speech recognition editors, QA specialists, and others involved in clinical documentation and data capture. With their knowledge, skills, and experience in patient documentation, these professionals can help physicians in documenting the details of each individual patient.

With the increasing number of patients, chronic diseases, rising compliance and increasing documentation specificity, physicians can get overburdened and may not be able to address their huge documentation needs. According to the AHDI, documentation specialists can help them in the following ways.

Standardization of medical documents is very important for sharing them within an EHR system. The documentation should support the workflow of the practices as well. Healthcare documentation specialists understand the medical language, clinical practice, data integrity and have vast knowledge regarding the diverse technologies used to capture the data. They are also well-aware of the requirements of HIPAA and HITECH, workflow and processes, and partner with physicians in ensuring flawless clinical documentation.
Speech recognition technology is ideal for EHR as it can save the time of physicians as they can simply dictate relevant details into the electronic record system. However, there are several quality issues with SRT technology such as the dictation may not be clear enough for the voice recognition software to capture, software may fail to interpret certain accents, grammar or punctuations, dictation may involve contradictory details that need to be resolved and so on. Documentation specialists identify and correct these kinds of errors and ensure the integrity of medical records.
As the deadline for ICD-10 implementation is approaching, accurate and detailed documentation is essential for medical practices. Documentation specialists can perform quality checks on the required content of a patient encounter and ensure the accuracy of the documentation so as to help coders choose the most appropriate ICD-10 code.

The main job of healthcare documentation specialists involves monitoring the following discrepancies in documentation:

Wrong patient or wrong content including demographic mismatches
Wrong provider name
Wrong dates of service
Medication dosage errors
Right/left, male/female inconsistencies
Incorrect work types
Medical contradictions
Missing elements
Speech recognition errors

They optimize clinician time, coding and revenue efficiencies by ensuring accurate and complete documentation and providing a strong foundation for data integrity.

AHDI puts forward three solutions to improve the quality and potential of documentation specialists in healthcare practices:

Bring a laser-sharp focus to the essential component of documentation
Encourage the education of professionals who are specialized in documentation moving into new roles and new processes of documentation
Hire trained and credentialed documentation specialists for existing and future roles

Healthcare providers relying on transcription companies that provide EHR transcription should make sure that there is a well-trained quality assessment team that can ensure the accuracy of their vital documentation.

Better EHR Systems and Documentation for Ebola and Other Infectious Diseases

22-December-2014 Julie Clements Infectious Diseases Transcription

Ebola With the Ebola outbreak, the efficiency of electronic health records (EHRs) in handling infectious diseases has been questioned. This October, representatives from the Centers for Disease Control (CDC) and the Office of the National Coordinator for Health IT (ONC) co-hosted a webinar to discuss the inclusion of clinical decision support tools within EHR for effective Ebola screening. In November, Texas Health Resources (THR) informatics team shared some lessons learned in this webinar and their rapid learning and reconfiguration of processes regarding EHR. The team advocates better EHR systems with more functionality for Ebola and other infectious disease, which demand more comprehensive clinical documentation.

As per the Healthcare Informatics report, the lesson learned in the emergency department (ED) by the THR was that they had all elements to make a diagnosis, but they were not in the right place throughout the care. The state of physician workflow and the manner in which nurses entered data into the EHR ran parallel to each other without the appropriate level of communication. THR implemented the following changes with respect to the lessons they had learned from the webinar.

Redesign of Patient-screening Workflow – THR redesigned the workflow by including the patient screening with travel history, the core concept discussed in the webinar. In the redesigned workflow, the patient’s travel history is captured at the first point of contact with the ED staff and that data is to be made available for all caregivers. If the patient has traveled to countries with Ebola outbreak and the answer to any of the screening questions is positive, a pop-up identifies that patient as high-risk for Ebola with explicit instructions for next steps.
Redesign of EHR screens – In addition to redesigning patient screening workflow, new EHR screens were designed to manage detection and initial treatment. The new screens mainly focus on detecting infectious diseases, warning staff, isolating the patient and initial treatment.

THR is not only focusing on making enough changes into EHR for Ebola, but is also utilizing this situation to make necessary improvements for handling other infectious diseases. It is assumed that other healthcare systems are making similar changes to their EHR for addressing infectious diseases more effectively.

EHR Documentation and Medical Transcription

Making necessary changes to EHR alone can’t bring the efficiency your need. In the case of an infectious disease, patients first present with a set of symptoms, clinical signs and test results. Physicians are not very clear about the story at the beginning, but it evolves as the data is uncovered which eventually lead to a diagnosis and a treatment plan. EHR is supposed to provide meaningful information from the disparate pieces of patient data at the right time to expedite this process. Thus, complete and accurate clinical documentation is quite important and more attention is required with new functionalities, especially while incorporating travel history into the workflow.

It has been found that miscommunication and omission of vital information exist within EHR and we are not yet sure to which extent new functionalities can help in reducing such errors. So, when trying new functionalities, physicians need to ensure that the data they are using is complete and accurate. The role of medical transcriptionists is quite evident in this aspect, though not perhaps in the traditional manner. Physicians can opt for backend speech recognition editing by medical transcriptionists to ensure data quality. They can also use Discrete Reportable Technology (DRT) in which physician dictations regarding infectious disease treatment are transcribed with the help of transcriptionists and populated into relevant EHR fields to make sure the data within EHR is accurate.

Depression Associated with CAD and CVD Risks in Younger Women

18-December-2014 Rajeev Rajagopal Diseases and Conditions

A new research found that depressive symptoms in women aged 55 and younger is associated with higher risk of coronary artery disease (CAD) and adverse cardiovascular effects (chronic CVD or cardiovascular diseases) compared to men of the same age and older women. As the study points out, depression is linked to CAD and CVD risks in young women; the lead study author opines that this may be one of the risk factors that can explain why women are dying at a higher rate than men following a heart attack. The American Heart Association issued a scientific statement in 2008 which recommended that depression be formally considered as a risk factor for increased heart disease risk just as diabetes or hypertension. The new finding literally re-defines this recommendation by considering depression as a risk factor in young women.

The researchers investigated depression symptoms in 3,237 people with suspected or known heart disease while 34 percent of them were women of average age 62.5 years. These people were scheduled for coronary angiography to diagnose disease in the coronary arteries (the arteries which supply blood to the heart) and three years of follow-up. Here are the major findings of this study.

After adjusting for other heart disease risk factors, every one point increase in depression symptoms was associated with a 7 percent increase in the presence of heart disease in women aged 55 and younger.
Women aged 55 and younger who had moderate or severe depression were 2.17 times more likely to suffer a heart attack, die of heart disease or require an artery-opening procedure during the follow-up period than other groups.
Women aged 55 and younger who had moderate or severe depression were 2.45 times more likely to die from any cause during the follow-up period.
In older women and men, the symptoms of depression did not predict the presence of heart disease.

In the opinion of the leading researcher, younger women should take depression very seriously. He said that awareness of the association between depression and an increased risk of heart disease and death should encourage people to seek help. In addition to this, physicians should be aware that younger women are more vulnerable to depression and this may increase their risk of heart diseases. Physicians should ask more questions to them during the visit. Even though the risk and benefits of routine depression screening are not yet clear, the study points out that special consideration may benefit young women.

Primary care physicians should also take care to accurately transcribe their consultation reports so that the specialists to whom they refer their patients can get more information and develop an appropriate treatment plan. This is beneficial both from the point of view of efficient patient care and physician reimbursement.

Why Accurate Clinical Documentation Is Essential for Bariatric Surgery

MTS TEAM Medical Transcription

Weight loss surgery or bariatric surgery is very effective for severe and medically complicated obesity with associated risks, even death. This treatment is used when less invasive weight loss methods fail. However, there are several risks associated with the surgery itself such as blood clot, excessive bleeding, lung or breathing problems and so on. In addition to this, longer term risks and complications are there for the procedure according to the type of surgery. Clear and complete clinical documentation of patients’ health condition is essential to address these issues effectively and make the treatment effective. Accurate documentation is important for getting coverage also. Here are the major scenarios where documentation plays a crucial role in bariatric surgery.

Surgery Approval

According to the National Institutes of Health, bariatric surgery is recommended as a treatment option for severe obesity if a person weighs 100 pounds or more above the ideal body weight, or have a Body Mass Index (see our BMI calculator) of 40 or greater, or a BMI of 35 or greater with one or more obesity-related health conditions that are known to improve with weight loss attempts such as diabetes, sleep apnea, high blood pressure, osteoarthritis, GERD, or metabolic syndrome among others. Either physicians or non-physicians (dieticians or nurses) should document the patient’s clinical condition very clearly during their admission assessments so that BMI can be coded correctly. The medical history reports of patients should be complete and incorporate the results of all the treatments they have undergone to lose weight. It is very important to document the details of psychiatric evaluation (if any) in medical history. Patients undergoing this surgery should be between 18-70 years of age and must not have advanced or irreversible medical conditions including end stage liver disease, crohn’s disease etc. Patient demographics should be documented well for that along with the results of pre-operative tests.

Pre-authorization

Most insurers review requests for prior authorization on the basis of medical necessity. The medical necessity is determined on a combination of clinical data as well as the presence of indicators that affect relative risks and benefits of the procedure. So, the prior authorization requests should be accompanied by documentation that supports medical necessity. Generally, the documentation should include the following:

Details of diagnosis and description of the pre- and post- surgical treatment plans
Summary of the medical history and the last physical exam that includes height, weight, patient and family history, personal and social history and medications (past and current)
Details about the diagnostic and/or laboratory tests related to the diagnosis and co-morbid conditions if present
Details about substance abuse (if any) and how severe it is
Details about previous surgeries, hospitalizations, initial and follow-up nutritional evaluation, psychological evaluation and description of multidisciplinary aftercare plan
Pre-operative weight history including the details of weight loss attempts

However, the documentation requirements may vary according to the insurer. Follow up with the insurer to ensure if the documentation includes all the details.

Repeat Surgery

Repeat bariatric surgery is performed when primary surgery failed due to some reasons, or for the replacement of the gastric band. Most of the insurers provide coverage for this if the previous surgery was medically necessary. You also need to prove the repeat surgery is medically necessary for the patient. For example, certain insurers insist that replacement of an adjustable gastric band can be considered as a medically necessary procedure, if there are some complications (for example, port leakage) that cannot be corrected with either band manipulation or adjustments. Here too, there should be accurate and complete documentation that explains the reasons for repeat surgery and ensure that they support the medical necessity requirements of insurers.