Procedure note required documentation

[denisek1028]

Hello,

For a minor procedure (trigger point injection) is it necessary for a doctor to document "preop and postop diagnosis" or can they document "indication for procedure" or "reason for procedure?"

Thanks!

 

[Orthocoderpgu]

Hello,

For a minor procedure (trigger point injection) is it necessary for a doctor to document "preop and postop diagnosis" or can they document "indication for procedure" or "reason for procedure?"

Thanks!

A trigger point can be identified in the office and the area is not surgically opened. The reason for pre-op diagnosis is to justify the reason for the surgery. The post-op diagnosis is used to confirm the pathology for the procedures performed. I have seen where providers have opened up a patient and not found what they were expecting, and had to completely change the diagnosis and planned procedures. Trigger point injections are performed in the office. There is no "pre-op" vs "post-op" situation since the area is not being opened with a potential change in pathology. If the provider documents that the "Indication for Procedure" is a trigger point, your covered.

 

[TTcpc]

A trigger point can be identified in the office and the area is not surgically opened. The reason for pre-op diagnosis is to justify the reason for the surgery. The post-op diagnosis is used to confirm the pathology for the procedures performed. I have seen where providers have opened up a patient and not found what they were expecting, and had to completely change the diagnosis and planned procedures. Trigger point injections are performed in the office. There is no "pre-op" vs "post-op" situation since the area is not being opened with a potential change in pathology. If the provider documents that the "Indication for Procedure" is a trigger point, your covered.

I have an outsourced ASC billing group that is stating that the MD has to have the note in "op note" format as their patient was a pediatric patient would would not be able to tolerate injection procedure in the clinic setting so it was performed in the ASC under anesthesia when it is normally performed in the clinic by this MD - would you consider this the same? I personally would, but not getting a lot of momentum making this point with them.