Surgical Procedures in Office

espforu

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There are times when our doctors after seeing a patient does a minor office procedure. Do you know where I can get any guidence of how it should be documented?

I am saying they need to docuement the details of the procedure, all that has been documented is XYY procedure performed. I do no think this justifys coding of this procedure.

Can anyone help? We are a FQHC

Thanks,:)
 

Cyndi113

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The procedure has to be documented. If its a laceration repair, then only the repair should be reported. That is unless the patient had another problem the doctor had to evaulate.
Would need more information on the procedure to be able to help you. Can you give examples?

Thanks,
 

espforu

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The only thing documented would be like xyz procedure done. There is not documentation of the step by step.

Does this help?

Thanks
 

mitchellde

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no this is insufficient, a procedure report must be documented and there must be documentation of the time out that is now required before any procedure is performed.
The body part must be identified, the sterile prep, drape, anesthetic if any, the time out
then the procedure in a step by step fashion and the closing note of the response by the patient, as "pt tolerated the procedure well"
 

espforu

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Thanks,

That was my thinking. Do you know where I can get this in writing? I need to prove to the provider we can not code if it is documented. I have been looking for something to show, but I cannot find anything.

:)
 
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