Wiki 11200 - Cryotherapy - documentation requirements

brightpea

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I need additional input, please! One of my providers is arguing with me that simply stating in the pts note 'the pt opted for cryotherapy. consent signed. aftercare explained.' is sufficient documentation to support billing 11200. Part of their argument is that stating that the pt opted for cryotherapy infers that it was performed.

There is no mention of number of tags removed; or even that the procedure was actually performed. I'm about to show them the LCD for benign lesion removal where it describes documentation requirements for surgical procedures.

Am I wrong & just splitting hairs here??? Maybe I'm just too close to this case & can't think clearly. Anyone with a different perspective? I'm not asking the provider to detail & explain what cryotherapy is, but just amend the note to clearly state that cryotherapy WAS performed & X number of tags were removed.

Too much?? PLEASE HELP!!!
 
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