Facility Documentation Requirements for Interventional Techniques

Compliance and documentation for interventional techniques have a multitude of regulations but are an essential part of medicine. Developments in the mid-1970s irrevocably affected the role of documentation in medicine as a result of a dramatic nationwide increase in medical liability claims and awards and changes in the fledgling Medicare program, followed by the emergence of electronic review process in the 1980s. The Health Insurance Portability and Accountability Act (HIPAA), the Medicare Modernization Act (MMA), and the Affordable Care Act (ACA), each with numerous component regulations, propelled the growth and importance of documentation to an unimaginable level. All interventional techniques are considered surgical procedures. Documentation requirements include history and physical, indications and medical necessity, intraoperative procedural description, postoperative monitoring and ambulation, and discharge/disposition. Documentation requirements vary among interventional techniques; detailed documentation is required for hospital outpatient departments (HOPDs) and ambulatory surgery centers (ASCs), with lesser requirements for in-office practices.