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Documentation required for laceration repair

T

tracey66

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Can anyone tell me what is required documentation for a laceration repair? I know a site and lengthe are required, but do they need to state how the repair was done? ie. sutures, dermabond, etc? I thought I read somewhere this was needed but now I can't find it.
 
Thanks, I know that steri-stips are in an E/M, but I need to show the doctors proof that they have to document the type of closure. Can you tell me where it specifically states this. I have looked in the CPT, but it does not say what documentation is needed.
 
Docs always amaze me. Tracey, try showing them the definition of each level of repair. Since we can only code what is documented, show them what we are looking for.
 
tracey66 said:
Thanks, I know that steri-stips are in an E/M, but I need to show the doctors proof that they have to document the type of closure. Can you tell me where it specifically states this. I have looked in the CPT, but it does not say what documentation is needed.
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I do not know of any "concrete" literature that states you have to state if you use sutures, dermabond, etc. However, I would show them the beginning of the repairs section where it states the simple repair, intermediate (layered) and complex repairs. Explain to them that if they do not take the few seconds to write down or dictate how they closed the wound and with what, they are throwing their own revenue down the drain. For instance, they could be doing an intermediate closure, but do not document and all you can do is give a simple repair and there you go... $$$ down the toilet for something that they did do but were "too busy" to write it down or dictate it. Honestly I will never understand doctors sometimes. Either it is written down or it is not done... as simple as that. I get your frustration... been there, done that. At the very, very least they need to state if it was sutures, steri-strips, dermabond, etc so you know for sure how to even code it. I do know most of the time in the disposition/plan they say suture removal in 10 days or dermabond/steri strip will fall off on its own, etc. That at least lets you know what "material" was used for the closure but they still need to be more specific about what was done especially if debriding or if the wound was contaminated, ect. I know not a lot of help, but I tried ;)
 
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