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Documentation for Re-injections

  1. #1
    Location
    Knoxville, TN
    Posts
    39
    Exclamation Documentation for Re-injections
    Medical Coding Books
    Hi everyone
    I have a question about documentation and I knew that you guys are always awesome to help.
    We do a lot of Hyalgan and Cortizone injections here at our practice. I thought that for every claim we billed out we needed to have an impression listed in the medical record for that date of service. I was under the impression that each dictation should be able to stand alone.
    Well I have a physician assist and a doctor here who disagree. They said they were told that if a patient comes in for a re-injection and the diagnosis had already been established in a previous office visit then the only thing they needed to dictate were “reinjection right knee”. I just don't think that's correct. I think they should dictate the impression for every date of service. If there is no impression listed then I would go back and bill with the “sign and symptom” which isn't dictated either if they are just injecting the patient. My defense is this: If an insurance company ends up requesting the medical record for that particular claim and there isn't an impression listed and no sign or symptom we have no cause to be injecting that patient.
    I appreciate any help with this issue and if anyone could give me source to site so that I can show these guys the rule I would appreciate it.

    Christy Brown, CPC
    Johnson City, TN
    Christy Brown, CPC
    Humana, Clinical Guidance Coder
    Knoxville, TN

  2. #2
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    For starters, "re-injection right knee" means nothing without a description of the procedure and medication used, etc. A diagnosis must always be documented.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    I agree with you and Lisa. "re-injection of the knee"... for WHAT exactly? I'd go further to say; ... ask the provider where they got their information, WHO was it that told them they could do this? Typically the answer is, "outside auditors" followed by..... years ago when they were here"... Stick to your guns, you're correct - if insurance requested that specific date of service note, your facility would be paying back money! If there isn't a dx, a medical reason for the injection (or re-injection) stated, there's isn't a medical neccesity for the injection, there's nothing you can code! No payment.

    geez louise... why is it so difficult for them to document the dx and what they do and why? It's not just your providers, we have them here too! I just don't get it,... if there's one part of medical services that IS clear, that IS black and white - it's the fact that the providers are suppose to DOCUMENT their services, the dx, the treatment... why do they make it so complicated??
    Donna, CPC, CPC-H

  4. #4
    Location
    Albany, New York
    Posts
    456
    Smile
    I see cases where a copy of a previous office note is dated/ signed for the current visit/ procedure and the phrase..."No changes to the above".
    Karen Maloney, CPC
    Data Quality Specialist

  5. #5
    Location
    Knoxville, TN
    Posts
    39
    Default Thanks
    Thank you all so much,
    Sometimes even though you know your right it takes other people having the same opinion that makes you feel better.

    They are acutally dictating the procedure itself and the medications used so for that I give them credit, but they just aren't giving me the impression. The most I get sometimes is "Patient coming for another injections, other injections given 3 months ago worked.

    My feelings are if they are giving a series of Hyalgan injectionas and they only want to establish the DX in the documentation for the first injection and then refer to that documentation in the notes for the other 4 thats fine, but it would take just as much time if not more to dictate "impression same as ____ visit" as it would for them just to dictate osteoarthritis.

    They told me our CEO told them this. I don't doubt they were told something, but it might have been misinterpreted.

    Lol- I love what I do, but sometimes these docs can drive you crazy. Like I tell mine...If I don't bring these things to your attention then I'm not doing my job and if I'm not doing my job I'm not protecting you.

    Thanks again girls and Have a wonderful day!!!
    Christy Brown, CPC
    Humana, Clinical Guidance Coder
    Knoxville, TN

  6. #6
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Good point! Sometimes they get so argumentative that they simply don't realize that we are one their side. I don't know why they sometimes make it difficult on us to keep them up to speed and cover their rear-ends!
    Lisa Bledsoe, CPC, CPMA

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