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Wiki Handwritten procedure note`

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lindacoder

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Medicare patient had evac hematoma -

handwritten note reads:

Hematoma rt calf

procedure - evac hematoma rt calf

surgeon: Dr.

Anesth: MAC

EBL - min

CX - none

tol well.

Since this is handwritten is this enough to charge aspiration of hematoma - pt has Medicare? I'm thinking there is not enough here.

Thanks.
 
Assuming there is also a date, I don't see any reason the service wouldn't be billable, but I would ask the provider to specify whether it was an aspiration or an I&D.
 
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