Wiki Procedure documentation

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KoBee

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Can anyone tell me if this qualifies as enough documentation to support CPT procedure, I understand providers give the name of the procedure but i don't see them describing or explaining what they did. Is it to be assumed that they don't have to document in detail. Help :/


PLAN:
-DM foot education (discussed at great length how diabetes can affect your feet)
-Reviewed with patient the importance of vigilant at home foot care, and importance of tight glucose control.
-slant back performed on L1 with immediate relief
 
That's not going to cut it. Is that all there was? There has to be pre-procedure consent and info, description of the procedure, and post procedure disposition at a minimum. Also, if they are trying to report an E/M on the same date/encounter, that's REALLY not going to cut it.


Here is a spot where we discussed minor procedures and in-office documentation. It was a different procedure but the concept is the same.
 
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