Wiki E\M with Surgical Procedures


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"Podiatry" Example: Pt comes in for treatment of his foot, and toenail debridement. Physican does a exam and in the Exam talks about the toenails. In the Impression again talks about the toenails, and a Stage 1 ulcer. In the Plan he talks about doing the debridement of the toenails and the debridement of the Stage 1 ulcer.

Question: Can I bill for the debridement of the ulcer (11040) even though it is not mentioned in the exam or anywhere in the note with the exception of the Impression and Plan?????
It is documented ( depth ) in the Plan and Impression. Its not documented anywhere in the exam part of the note. I'm being told that if its not mentioned in the exam (EM) part of the note and only mentioned in the Plan and Impression then I cant charge for it. On the other hand I've been told that since its a Procedure it only has to be documented as to what was actually done, reguardless if it was not mentioned in the exam. Help!!!!!
In my humble opinion, I think this is a very gray area without seeing the actual documentation. I, personally, would not feel comfortable with this type of dicatation. Several questions came to mind:

Was there documentation suporting the level of tissue removed; the method use to debride, and the character of the wound before and after debridement? Are there underlying issues; such as diabetes? In the event of infection, what would one reference to, regarding the previous condition of the wound, if there was no exam notated in the previous visit? If may just be me...but I'm a stickler for documention.
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The bottom line is that its stated in the "plan and impression" . From the information in the plan and impression I know what level he went to and the reason (dx) for doing it. This is done in office, the problem is I'm being told that I CAN NOT code for the debridement of the ulcer on the foot b\c it is NOT stated any place in the note\documentation that he even looked at it, with the exception of the plan and impresson. I'm just trying to find out when I bill for office procedures (lesions, debridements, joint injections) how or where does it need to be documented????:mad: :confused:
I know this is frustrating...documentation and compliance always is. I have some other resources I can contact. I'm really curious as to what other CPC's and instructors have to say...You presented a very good question. I'll let you know what my "guru's" comments are.
If a provider states in the course of an E/M service record that a procedure was performed then it can be coded.

However, if there's ambiguity about it "plan to do", "consider" or the like, it would be prudent to simply code an E/M service; you really have no way of proving anything further being performed.

Providers, too, must be educated on how we (coding and compliance folks) need to see bedside and office procedures written. Although it might seem clear to them that "yes, I debrided the wound," we and the payer side have no way of knowing that outside relying on their records.

Although it's gray, I'd work internally to set up a uniform system for clinicians and coders.

Good luck!
Here's one response I received for your question~

"That is technically correct. It is generally not a good idea to document procedures in the “plan” section of the note because this usually means that they are documented as a provider's intent to do something, which as I mentioned, counts for zero. But as long as the procedure is documented in the past tense with enough detail to support the code it can technically be documented in the plan, above the history, on the back of the paper, or on a napkin (as long as it has been added to the medical record and contains patient data on it). Enough details to support the code and documented-in-the-past-tense are the important parts.

Putting a procedure note in the middle of an E/M encounter (within the Exam) is just as unwise as putting it in the plan. It can often lead to the E/M and the procedure appearing as one mixed service, instead of a complete E/M and a separately identifiable procedure.

Ideally, the full E/M note would be completed, and then be followed by a separate and distinct procedure note written in the past tense that contains enough detail within it to bill the code."
I really see both sides. I'm looking at the note and in the Impression he will state\list the diagnosis\problems. The next seprate section he will have the Plan with which is what he did\or treatment options to address the diagnosis listed in the Impression.

For me I look at it and can tell what was done and can code from it. But because its not mentioned in the Exam part of the note how do you know for sure he did it, if he didnt even exam it? I've talked to an Auditor I know and she says that since its a Procedure it just has to been listed somewhere in the note as to what was done.

On the other hand and I know everyones thoughts on this, and I should have my answer by just this alone but......

The place I'm working at now was Audited my Medicare ( not for this reason but b\c they were using a code that they really shouldnt have been using which raised a RED flag for Medicare, and this was the only reason for the Audit ) but you know Medicare since they were already here why not take a look to see what else they could find.....thus this problem....Medicare said the same thing that Kevin stated if its not mentioned anywhere in the note how do you really know it was done, just by stating that you did it, but you didnt even look at the site or do you know for sure??? Long story short we lost, and had to give back lot of money!!! ( This was before I got here thank god!!!) Based off of this information alone I should not even waste my time with this right??? But I know from my own experience several of us coders have not applied this to our coding guidelines.
The fact that the stage I ulcer was not mentioned in Chief Complaint nor in the Exam would raise a flag for me if this procedure was intended for the patient - could be human error on the part of the physician. I would request a clarification why this procedure was performed in the absence documented of medical necessity, and if it is in fact medically necessary and was agreed upon, an addendum should be submitted.