Wiki Op-note documentation required for coding yags

[JWalden]

Hello,
Do I need the jouls/shots/energy in order to code yag procedures? I have a few op-notes that are missing this information and I feel that it is absolutely necessary but cannot find an article or guidelines to support this.

 

[Cheezum51]

You should be good with just the operative notes but I always suggest that the laser specific info you mention be included in the notes.

Tom Cheezum, OD, CPC, COPC

 

[JWalden]

You should be good with just the operative notes but I always suggest that the laser specific info you mention be included in the notes.

Tom Cheezum, OD, CPC, COPC

Thank you for responding. The operative notes are just templates with no additional information for the specific cases. They did an addendum stating that the laser settings were not documented during the procedure but the physician confirms the procedure was done. The addendum was not signed by the physician or anyone else that was present for the procedure. To me it seems like there is no documentation so it didn't happen and I shouldn't code it. Would you provide me with some further guidance in light of the additional information I have provided?

 

[Cheezum51]

Thank you for responding. The operative notes are just templates with no additional information for the specific cases. They did an addendum stating that the laser settings were not documented during the procedure but the physician confirms the procedure was done. The addendum was not signed by the physician or anyone else that was present for the procedure. To me it seems like there is no documentation so it didn't happen and I shouldn't code it. Would you provide me with some further guidance in light of the additional information I have provided?

Send the record back for the physician to sign.