Results 1 to 2 of 2

Procedure missing required elements

  1. Default Procedure missing required elements
    Medical Coding Books
    Had a discussion today regarding when is it appropriate to send a report back to the radiologists for missing documentation. I am under the impression that it is not appropriate to do this and the record is to be coded based off of the available information that is in the report. Found out the previous billing company used to set aside these reports to return to the radiologists to have an addendum completed. Examples I have are for ultrasound and duplex studies.

    If an ultrasound was missing elements for a "complete" study it would be returned to obtain this additional information instead of it being coded as a "limited", same thing for duplex studies when all that is originally noted is the color flow but missing the other documentation requirements.

    I am trying to work with the radiologists on the quality of their documentation but while I do this need to know if it's okay to return for the addendum or it is coded "as is"

  2. Default
    The golden rule I follow is, "If it's not documented, it wasn't done." Sometimes it's a judgement call about whether to query. It's also a matter of the workflow of your group. Personally, if the physician is trying to bill a complete US, but they only talk about one structure, I'd down code it and move on. However, if they talk about most of the structures and are only missing one I'd probably query.

Similar Threads

  1. Required documentation in Procedure Note for TESI?
    By chriscottd in forum Anesthesia
    Replies: 3
    Last Post: 05-06-2015, 11:27 PM
  2. Coordination of Care vs 3 required elements
    By mcgrathk0342 in forum Auditing General Discussion
    Replies: 0
    Last Post: 11-26-2013, 02:29 PM
  3. REQUIRED ELEMENTS for common procedure in PED ED
    By kviolet in forum Emergency Department
    Replies: 3
    Last Post: 02-07-2012, 06:19 AM
  4. Procedure Report Required?
    By KLRuhe in forum Auditing General Discussion
    Replies: 1
    Last Post: 02-11-2011, 03:23 PM
  5. AWV - Missing Elements
    By klimek16 in forum Medicare Regulations
    Replies: 2
    Last Post: 01-24-2011, 10:36 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.