Podiatry Coding & Billing Alert

Learn what to do when the op note and pathology report say different things. Sometimes the reports you receive from your physician/surgeon only leaves you confused on what codes to use in your claim. Resolve this dilemma by reading through the documentation with scrutinizing eyes, and you’ll be able to determine the appropriate codes and areas for clarification in no time. Examine the following op note: Preoperative diagnosis: Unknown soft tissue mass, left foot Postoperative diagnosis: Unknown soft tissue mass, left foot Operation: Excision of subcutaneous soft tissue mass, left foot Gross findings and procedure description: Anesthesia: Local with IV sedation Hemostasis: Pneumatic tourniquet at 250 mmHg x 18 minutes Estimated blood loss: Less than 5 mL Materials: Xeroform gauze and 3-0 Prolene Post-op injections: 5 mL 0.5 percent Marcaine plain Procedure: This patient was taken to the operating room and placed on the operating table in supine position. Following [...]