Wiki One operative session - 2 reports

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kparkhurst

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I have a physician who is documenting 2 separate reports for procedures done within the same operative session. Ex. endoscopic carpal tunnel and trigger finger release. Separate incisions are made which qualify for modifier 59 but I am uncomfortable with the 2 separate reports. Has anyone seen this before?? Is this acceptable??
 
There is nothing wrong with this practice. I have had providers do this many times. You just code both procedure and use a modifier if appropriate.
 
I actually prefer it if my providers dictate 2 distinct notes. Especially if there might be two seperate carriers involved, etc...
 
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Some of our GI physicians will do this when they perfrom an EGD and Colon same session. I prefer it this way as well.
 
yes, for the coders this makes life easier, you just have to remember that since they were done on the same day, they get billed on the same HCFA or UB04. Be sure to check for bundling issues of course......
 
thanks everyone - my biggest problem with this provider is that he does not fill out his superbills and is lax in his dictation. I had one this week where one op report was dictated while the other was not - if his PA did not fill out the superbill, I would never have known about the second procedure!
 
Not illegal BUT ...

There is no reason why the provider cannot or should not dictate two separate notes. Frankly, I'd be happy if one of my docs would at least use paragraph breaks!

HOWEVER ... it may pose a problem if the coder does not have a good way of knowing that there is more than one note for this Date of Service. So good communication between the surgeon (and/or his PA, NP or OR staff) and the coder is vital for this to work and ensure that you capture all the relevant charges.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
kparkhurst said:
I have a physician who is documenting 2 separate reports for procedures done within the same operative session. Ex. endoscopic carpal tunnel and trigger finger release. Separate incisions are made which qualify for modifier 59 but I am uncomfortable with the 2 separate reports. Has anyone seen this before?? Is this acceptable??
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There is nothing wrong with this practice. You just code both procedure and use a modifier if appropriate.
 
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