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procedure note

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    Wiki failed endometrial biopsy documentation

    Hi! I have a provider that wants to bill out for a failed endometrial biopsy, which I have no problem with except .... He did not document the biopsy and is stating that it says under "Cervical Stenosis" why it was stopped. This is his "note:" "Cervical stenosis (uterine cervix): Failed...
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    Wiki Where can I find what is required to be in a procedure note?

    Does anyone know where I can find out what needs to be in a specific procedure note? i.e: Laceration Repair note, Reduction, etc. We have providers stating the information is in the documentation but it isn't always complete. I was hoping there was something that spelled out what information...
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