Trendale
Guru
Hello,
Does anyone have a supporting documentaion link that states the physcian needs to document all surgeries, even if it is a closed reduction ( Treatment) of distal radial FX? I have a doctor that wants me to bill this without documenting it. He did a brief inpatient consult (99251) and stated he applied the patient in a cast and to F/U with him in four weeks. When the patient did come back in 4 wks he charged a new PT visit, when in essence it should have been a P/O visit if he did a closed reduction. To me, the consult should be coded and the cast only. Where is the information for me to code the closed reduction (25600)? His response was I should be able to determine what he did by looking at the DX from the xray report.
I don't know about you, but the way I was trained, if it is not documented, it never happened.
Thanks!
Does anyone have a supporting documentaion link that states the physcian needs to document all surgeries, even if it is a closed reduction ( Treatment) of distal radial FX? I have a doctor that wants me to bill this without documenting it. He did a brief inpatient consult (99251) and stated he applied the patient in a cast and to F/U with him in four weeks. When the patient did come back in 4 wks he charged a new PT visit, when in essence it should have been a P/O visit if he did a closed reduction. To me, the consult should be coded and the cast only. Where is the information for me to code the closed reduction (25600)? His response was I should be able to determine what he did by looking at the DX from the xray report.
I don't know about you, but the way I was trained, if it is not documented, it never happened.
Thanks!