Office Procedure Documenation

rmooney1114

Networker
Messages
47
Location
Monson, MA
Best answers
0
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

Networker
Local Chapter Officer
Messages
57
Location
Tacoma, WA
Best answers
0
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. :rolleyes:
 
Top