Wiki Office Procedure Documenation

[rmooney1114]

When a provider is performing a procedure in the office, should the provider be documenting a description of the procedure performed, i.e. how patient tolerates, any complications etc, or is simply stating "Anoscopy done today" enough to bill for that procedure..
P.S. im pretty sure i know the answer to this question i just need some reassurance and back up lol.
Thank you!!

 

[elljay68]

Right???

Ruth!! You and I are banging our heads against the same keyboard!!! I'm trying to figure out what HAS to be documented when a provider does an office-based procedure. Specifically, does there have to be an indication of how the patient tolerated the procedure and if there were any complications, or is that simply a best practice?

Also, if he's performing an anoscopy, best practice includes documentation of whether abnormalities were observed or not. HOWEVER, I can't cite a source to confirm that except common sense.