Procedures

[ivygirl18@hotmail.com]

Hello,

I have some questions regarding procedures done in the office. Hopefully someone can help!

1- If lesion size is not documented, can it still be billed using the code for the smallest size in that area?
2- Must instrument used be documented?
3- Can size be documented as "dime sized" "pea sized"?
4-Do you have any resources you use that are helpful to know what must be documented for a procedure? I have the procedures book from Optum.

 

[CodingKing]

Hello,

I have some questions regarding procedures done in the office. Hopefully someone can help!

1- If lesion size is not documented, can it still be billed using the code for the smallest size in that area?
2- Must instrument used be documented?
3- Can size be documented as "dime sized" "pea sized"?
4-Do you have any resources you use that are helpful to know what must be documented for a procedure? I have the procedures book from Optum.

If not documented, Option 1 code the smallest. Option 2 is wait for pathology report and use that measurement, however since tissues shrink it will be smaller than if provider measured from the start. At least chances are it could be a higher code.
pea or dime sized is not sufficient it needs to be measured.

I'm not sure if these will be helpful or not

http://www.hcpro.com/HIM-66438-859/Do-not-use-pathology-measurements-to-report-a-lesions-size.html

https://www.aafp.org/fpm/2013/0100/p11.html

 

[ivygirl18@hotmail.com]

Thank you very much for your help!