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Wiki coding off from a hand written procedure from the procedure doctor

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vsmith

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Can you code from a hand written procedure from the procedure doctor? The procedure does dictated at the hospital when I let him know that he did not dicated the procedure at the hospital.
 
Procedure documentation

As long as the procedure is adequately documented, yes, you may code from a handwritten procedure note. "Adequately documented" will include legibility of the note, date of service, clear indication for procedure, clear description of what was done (not just a title), clear indication of who is performing the procedure and the provider's signature and date.

I have coded a procedure (e.g. laceration repair) when it is only handwritten and not dictated/transcribed.

BUT ... most hospitals require a dictated operative note for anything requiring anesthesia and/or not done at bedside.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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