desertcoder
Contributor
I am looking for redacted documentation examples for sclerotherapy, varithena, transcatheter embolization, and venaseal for my provider. I am trying to educate him that 3 or 4 lines is NOT enough to aid in reimbursement and/or appeals.
His current documentation for sclerotherapy reads as follows:
Pt was brought into procedure room. Consent was obtained. Questions were
addressed and discharge instructions reviewed. The right thigh varicosities were marked with
ultrasound guidance.
While lying flat the right thigh varicosities were injected with 3 and half cc of polidocanol microfoam
using ultrasound guidance. The patient was asked to dorsiflex the ankle of treated limb to limit flow
of polidocanol into perforating veins. The common femoral, deep system and superficial veins were
the evaluated for flow and compressibility prior to compression placement. A rolled compression
bandage was applied to varicosity treated and compression stocking was applied on top of this.
Patient ambulated for 15 minutes prior to getting into their vehicle. Pt was instructed to leave this
on x 48 hours; in addition to daily wear of 20/30mmHg compression stockings x 14 days. Post
procedure ultrasound was scheduled within 7-10 days. Also instructed to avoid heavy exercise for
one week, and extended periods of inactivity. Walk daily for 10 minutes over the next month.
His current documentation for Varithena (36465) is as follows:
Pt was brought into procedure room. Consent was obtained. Questions were
addressed and discharge instructions reviewed. The right below-knee great saphenous vein marked
with ultrasound guidance. The Varithena Canister was activated and canister was primed and purged
as required in the instruction for use.
While lying flat the below-knee great saphenous vein injected with 4 cc of Varithena microfoam
using ultrasound guidance. The patient was asked to dorsiflex the ankle of treated limb to limit flow
of Varithena into perforating veins. The common femoral, deep system and superficial veins were
the evaluated for flow and compressibility prior to compression placement. A rolled compression
bandage was applied to varicosity treated and compression stocking was applied on top of this.
This is not enough--he has asked for other examples to compare and I am looking to fellow coders to help. Please forgive me if I have posted this in the wrong forum. Any assistance you can provide is welcome!
His current documentation for sclerotherapy reads as follows:
Pt was brought into procedure room. Consent was obtained. Questions were
addressed and discharge instructions reviewed. The right thigh varicosities were marked with
ultrasound guidance.
While lying flat the right thigh varicosities were injected with 3 and half cc of polidocanol microfoam
using ultrasound guidance. The patient was asked to dorsiflex the ankle of treated limb to limit flow
of polidocanol into perforating veins. The common femoral, deep system and superficial veins were
the evaluated for flow and compressibility prior to compression placement. A rolled compression
bandage was applied to varicosity treated and compression stocking was applied on top of this.
Patient ambulated for 15 minutes prior to getting into their vehicle. Pt was instructed to leave this
on x 48 hours; in addition to daily wear of 20/30mmHg compression stockings x 14 days. Post
procedure ultrasound was scheduled within 7-10 days. Also instructed to avoid heavy exercise for
one week, and extended periods of inactivity. Walk daily for 10 minutes over the next month.
His current documentation for Varithena (36465) is as follows:
Pt was brought into procedure room. Consent was obtained. Questions were
addressed and discharge instructions reviewed. The right below-knee great saphenous vein marked
with ultrasound guidance. The Varithena Canister was activated and canister was primed and purged
as required in the instruction for use.
While lying flat the below-knee great saphenous vein injected with 4 cc of Varithena microfoam
using ultrasound guidance. The patient was asked to dorsiflex the ankle of treated limb to limit flow
of Varithena into perforating veins. The common femoral, deep system and superficial veins were
the evaluated for flow and compressibility prior to compression placement. A rolled compression
bandage was applied to varicosity treated and compression stocking was applied on top of this.
This is not enough--he has asked for other examples to compare and I am looking to fellow coders to help. Please forgive me if I have posted this in the wrong forum. Any assistance you can provide is welcome!