Documentation of bilateral procedures

CJoy0724

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Traverse City Michigan
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Does anyone have documentation guidelines for procedures being done bilaterally? We have a provider who performed a bilateral total hip replacement, and instead of documenting each side separately he added this to the beginning of the body of the note:

"The remainder of the operative dictation is accurate for the left hip. Once the left hip was completed we then proceeded to perform the right hip. The procedure reads the same for both hips."

Is this acceptable? My gut says no, but I cannot find anything either way. He does state bilateral at the top, discusses both hips in the operative indications, and lists the implants separately.
 

jsalzer50

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Vancouver, WA
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Total Hip Replacement

I'm a coding student, and cannot provide a definite answer, but I find it's strange that the physician didn't document the full report of the right hip replacement... it seems that the details of such a major procedure like this are different every time (for each hip/side of the hip...), and it seems those details are important.

Should we query the physician in this case and ask if he/she is willing to dictate more notes about the right hip replacement?

In CPT, I'm looking at 27130, with several options depending on details...I would consider adding modifier -50 for bilateral procedure, but only if those brief notes about the R side are sufficient.

- Jake
 
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