Don’t Let Bad Documentation Get Under Your Skin

Don’t Let Bad Documentation Get Under Your Skin

Work with your providers to ensure that accurate documentation of subdermal contraceptive procedures is recorded.

When a provider inserts a subdermal contraceptive implant and documents that the device was “inserted according to the manufacturer’s instructions,” this does not fully relay the steps taken to complete this portion of the procedure. Suppliers may provide directions and recommended implantation techniques, but ultimately it is the provider’s responsibility to document in the medical record the actual steps taken to insert the device.

As coders, we know that documentation is key. When a provider documents a procedure, we rely on them to accurately describe the steps taken to complete the procedure so we can abstract the required elements to code correctly. Let’s look at examples of insufficient versus sufficient documentation.

Incomplete Documentation

Procedure Note: The inner side of the left arm was cleaned with BetadineX3 and infiltrated with 1% lidocaine with epinephrine. The contraceptive rod was inserted according to the manufacturer’s instructions without complications. The rod was palpable under the skin after insertion. The insertion site was closed with a bandage and a pressure dressing was applied. Post-insertion instructions given to patient.

Because this note does not fully describe the steps taken to insert the device, we have no way of knowing how the provider inserted the product.

Accurate Documentation

Procedure Note: Patient in the supine position. The inner side of the left arm was cleaned with BetadineX3 and infiltrated with 1% lidocaine with epinephrine. The needle was then brought parallel to the skin, and while tenting the skin, the needle was advanced through the subcutaneous tissue. The needle was then withdrawn, leaving the device in place. A bandage was placed over the site. Patient tolerated the procedure well. Postoperative instructions given.

The above note clearly describes the steps taken to insert the device, which is coded as:

J7307    Etonogestrel (contraceptive) implant system, including implant and supplies

You will also use the following CPT® codes, as applicable, to bill for the implant’s insertion and/or removal:

11981    Insertion, non-biodegradable drug delivery implant

11982    Removal, non-biodegradable drug delivery implant

11983    Removal with reinsertion, non-biodegradable drug delivery implant

Remember to report the applicable ICD-10-CM encounter code on the claim, as well:

Z30.017 Encounter for initial prescription of implantable subdermal contraceptive

Z30.46   Encounter for surveillance of implantable subdermal contraceptive

Removal of a subdermal contraceptive device is much more involved than inserting it and requires even more attention to detail in the provider’s documentation.

Get Providers Onboard

It can be difficult to approach your providers if they have been documenting the same way for a long time, but keep in mind that a “joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedure,” according to the 2022 ICD-10-CM Official Guidelines for Coding and Reporting. You can refer to this new 2022 ICD-10-CM guideline when you need to query providers for accurate assignment of CPT® and ICD-10 codes.

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Morgan Jones
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Morgan Jones, CPC, CPCO, CDEO, CPB, COBGC, CPRC, has more than 10 years of experience in healthcare and is currently a specialty coder for a large health service company that spans across the country. Jones is finishing her associate degree at a local community college and is a member of the Franklin County, Mo., local chapter.

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