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Wiki Billing for cancelled procedure after induction of anesthesia

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suskim07

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Clearwater, FL
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Good morning. We are having a discussion in our office. Does anyone know if there are specific guidelines as to how a provider needs to notate/ dictate a canceled procedure. Can this be a handwritten? Case in point, the provider hand wrote the reason for the cancelled procedure on a Outpatient Surgery Center Operative Progress Note/Discharge Plan. Any assistance would be helpful.
 
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As long as the information is authenticated by the provider and included in the medical record, I don’t think it makes any difference if it’s handwritten or not. Why is there a concern about it and how does it affect coding in this particular situation?
 
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thomas7331 said:
As long as the information is authenticated by the provider and included in the medical record, I don’t think it makes any difference if it’s handwritten or not. Why is there a concern about it and how does it affect coding in this particular situation?
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Yes. I felt the information the provider furnished was sufficient. However, another coder in my office disagreed. She felt a dictated note should be provided. Is there somewhwere I can locate guidelines to substantiate this?
 
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suskim07 said:
Yes. I felt the information the provider furnished was sufficient. However, another coder in my office disagreed. She felt a dictated note should be provided. Is there somewhwere I can locate guidelines to substantiate this?
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I’m not aware of any such guideline. Some organizations may have internal policies to this effect but I’ve never seen it written as a general requirement.
 
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thomas7331 said:
As long as the information is authenticated by the provider and included in the medical record, I don’t think it makes any difference if it’s handwritten or not. Why is there a concern about it and how does it affect coding in this particular situation?
Click to expand...
Thank you for your assistance.
 
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