Wiki Operative Notes

[Desperate Denise]

Hey everyone!!

Can someone direct me to a website or article that explains specifically what a physician needs to dictate in his operative report when doing multiple shoulder surgeries. For example, the physicians are dictating "a subacromial decompression was performed". That is not enough. Same for "distal clavicle excision" (29824), "debridement of labral tear" (29823).

Second question. When the physician does a debridement of labral tear (Type 1) is it billable with 29827 and 29826? If it is, do I use modifier 51 or 59?. Do they have to dictate that they debrided anteriorly and posteriorly? I read somewhere that the labral debridement was included in the 29826.

Sorry for so many questions - I am just trying to maximize reimbursement but also want to be sure the dictations are appropriate.

THANK YOU!!!

Denise

 

[PLAIDMAN]

Hey everyone!!

Can someone direct me to a website or article that explains specifically what a physician needs to dictate in his operative report when doing multiple shoulder surgeries. For example, the physicians are dictating "a subacromial decompression was performed". That is not enough. Same for "distal clavicle excision" (29824), "debridement of labral tear" (29823).

Second question. When the physician does a debridement of labral tear (Type 1) is it billable with 29827 and 29826? If it is, do I use modifier 51 or 59?. Do they have to dictate that they debrided anteriorly and posteriorly? I read somewhere that the labral debridement was included in the 29826.

Sorry for so many questions - I am just trying to maximize reimbursement but also want to be sure the dictations are appropriate.

THANK YOU!!!

Denise

http://depts.washington.edu/uwpsite/compliancesite/training/postcia/surgicaldocumentationbillingstandards/001sdbs.html

I was given this link by one of our forum members in reference to this same question, I found it helpful.

documentation requires a DESCRIPTION of the procedure...not the name of the procedure..no he cannot say "subacromial decompression" (in body of op) he must describe everthing he did to achieve this procedure. I also know for a distal clavicle excision he must state at least 8-10 mm or 1cm of the clavicle was resected....I have been denied on both of these in the past for insufficient documentation. Remember when you were in school and your math teacher said "show your work" ....same principle.

You can charge for labral debridement so long as it is in different "area" of shoulder...the 29826 is extra-articular work so the 29822 can be used since it was done inside of the joint.

Keep in mind i have not read the op report.
There are several AAOS articles regarding the labral debridement, and distal clavicle documentation......if you dont have access ...you can send me email....i will look them up.

hope it helps!