Wiki Would You Bill For This??

[EZANOTTO]

I have an MD who states "I have documented well above and beyond the requirements for billing". He is billing a 27193 for the documentation below.

Pre Op Diagnosis: Right pubic rami and sacral fxs
Post Op Diagnosis: Right pubic rami and sacral fxs
Procedure(s) Performed: Closed treatemnt of pubic rami and sacral fxs without manipulation
Anesthesia Type:none


Blood Loss: none
Urine Out: none
Fluid Replacement: none
Blood Products: none
Implants: None
Complication(s): none
Specimen(s) Removed: none


Wound Class: 1. Clean
Findings / Comments / Complicationslan non op treatment of pelvic fxs.

I do not think that the note is descriptive enough to bill that level of CPT. I cannot find any resource that will tell me that he has documented appropriately to constitute 27193. Does anyone have supporting specs around billing Non-Operative Fracture treatment?

Thank you,
Elena

 

[OCD_coder]

It can be defended as it is stated, it's clear the provider is providing 90 days of care for the pelvic fracture. Would we like a complete sentence? Yes. But there is no surgery being performed and it's clear that it was the moment he/she decided non-operative treatment will commence.