Wiki Documentation resources


Shepherdsvlle, KY
Best answers
I am trying to provide documentation resources to my providers, showing them what needs to be included in operative/procedure reports. I have researched, but can only seem to find info on medical necessity, ordering of supplies, home health, etc. Does anyone have good articles on what needs to be in a note (medical necessity, risks of procedures, description of procedure, etc.) ? My providers sometimes seem to think that stating the did a certain procedure with no complications ( ex: SIS performed with no complications) is good enough to bill it! Thanks in advance!
Assuming SIS is saline-infusion sonography, I'll just use 58340 and 76831 for argument's sake. Even though those components have to be going simultaneously, going off the US piece alone, at the beginning of the Radiology section in CPT, it says:

"Guidelines to direct general reporting of services are presented in the Introduction. Some of the commonalities are repeated here for the convenience of those referring to this section on Radiology (Including Nuclear Medicine and Diagnostic Ultrasound). Other definitions and items unique to Radiology are also listed.".... "A written report signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation."

Under the heading for Diagnostic Ultrasound:

"All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated. For those codes whose sole diagnostic goal is a biometric measure, permanently recorded images are not required. A final, written report should be issued for inclusion in the patient's medical record."... "Ultrasound guidance procedures also require permanently recorded images of the site to be localized as well as a documented description of the localization process, either separately or within the report of the procedure for which guidance is utilized."

I also found this: and this and this

(If I'm anywhere in the ballpark of your example) Using "SIS performed with no complications" wouldn't even come close to describing, well, anything really. Documentation requires a stated, medically necessary, purpose or reason for the procedure, at least some form of a working diagnosis, certainly a final diagnosis or finding, an explanation of the procedure from start to finish, and in the example above, all of the findings from the US itself.

I think the most valuable and credible resource you can use to GENTLY make a point to the provider is the CPT book and its guidelines. I got certified in "conflict resolution" (no idea there was such a certification, but...) and I'd suggest approaching it from a reimbursement angle. For example, while pointing it out in the CPT book, "Even though I know you did this procedure, the CPT book says I need to have [such and such] documented in order to bill for it, and since [name of insurance] follows the CPT guidelines, they won't pay if I don't meet these guidelines." You're not lying or being deceptive in the least bit, you're not pointing fingers at the provider, you're placing yourself on the provider's "side" of the game with the goal of making him/her money, and by "blaming" an inanimate object (the CPT book), you've created a dynamic where there's no actual person to dispute it with. You're not tricking the provider or doing anything that would constitute any form of disrespect; you're just pointing out the actual facts in a way that demonstrates you really don't have any control over it, which is true. The key is to avoid putting the provider on the defensive and to make sure he/she knows you're on "their side." One thing NOT to do is "play stupid." That will always end badly.