Coding repairs

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3
Location
Lebanon, MO
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Can someone tell me when doing a wound closure and the size of the wound is not documented do you code this at all? Can you tell me where to get the documentation as to how to code this?
 

j-fowler57

Guru
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I have this issue as well and I go back to the doctor and have them do an addendum or have them hand write the answer ( then have report rescanned if necessary ) on the OR report. I don't code it without the documentation. Good luck!!:)
 

mitchellde

True Blue
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13,532
Location
Columbia, MO
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I agree, I have however been instructed several times to default to the least size code available.. I am not comfortable with that, I too will not code with the documentation.
 

j-fowler57

Guru
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I too was told by co-workers that I could use the least as a default but have never done so. Never felt comfortable doing that either. I will go that extra step to get the correct info needed.
 
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4,466
Location
Milwaukee WI
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Go back to physician

I go back to the physician, but ...

I won't give them forever to amend their documentation to include the size. I tell them up front that if I do not hear back within 2 business days that we will default to the smallest size.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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