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missing documentation

J
Wiki New patient, Comprehensive or Intermediate exam

Hello - fairly new to Optometry/Ophthalmology coding... wanted to reach out for suggestion. Provider performed new, exam but didn't perform or document gross or confrontation visual field, nor vessels. Would this disqualify from a Comprehensive visit and down code to a Intermediate? I reached...
- jessica907
- Thread
- Sep 15, 2022
- comprehensive intermediate missing documentation
- Replies: 2
- Forum: Ophthalmology/Optometry
K
Wiki Missing laceration length

We have a debate going on with providers. They state that if the laceration length is not stated, we should code the lowest level for example 12001 where it shows "2.5 cm or less". I am not in agreement. I believe that the length of wound is one of the necessary pieces of information needed to...
- KRZollinger67
- Thread
- Jun 17, 2022
- laceration repair missing documentation wound repair
- Replies: 4
- Forum: Medical Coding General Discussion
L
Wiki query for time spent with patient?

I have this encounter for a procedure as outpatient, the procedure was canceled because the patient's INR was too high and the patient was sent to ER, our doctor called ER and described the patient's problem and what they were doing to remedy it. I was told that I have to query for time spent...
- Libest
- Thread
- Mar 30, 2018
- documentation of time leading query missing documentation
- Replies: 0
- Forum: Medical Coding General Discussion

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