Results 1 to 8 of 8

Incomplete op report

  1. #1
    Default Incomplete op report
    Medical Coding Books
    Doctor did YAG Capsulotomy,66821, but did not include total engery, exposures, etc. on the report. A query was sent to the doctor's office and came back stating "information not available". The doctor did the procedure, but this is an incomplete report. I'm coding for the facility side. Can this be coded with an internal billing note indicating that the deficient info was requested but not available? Thanks for your input.

  2. #2
    I guess my question is WHY isn't this information available? I realize the procedure was performed, but if the op note wasn't "complete" then I don't see how the physician or facility could bill for it appropriately....until it is complete.

    Anyone else?!

  3. #3
    Albany, New York
    Hi Coder Guy....

    For what type of facility do you code?
    Karen Maloney, CPC
    Data Quality Specialist

  4. #4
    I code for an ASC. These procedures were performed in 06/2008 and I can only assume the information is not available because it wasn't dictated at the time it was performed and the doctor cannot recollect the specifics. The doctor uses a op report form that he fills out by hand and he indicated Capsulotomy and gave an appropriate DX, but omitted the info referenced above which is typically included.
    Last edited by coderguy1939; 03-31-2009 at 11:02 AM.

  5. #5
    I figured! This is why documentation at the time of service is sooooooo important. No late entries! I would probably go ahead and bill it anyway, the procedure WAS performed, you have some documentation, that could be your argument. Does the payer require you have the information that you are missing?

  6. #6
    Albany, New York
    Thanks, I was just wondering because I codeAmb Surg in a hospital setting.
    For the procedure you describe, I don't have to have the info you are missing to code the procedure.
    Karen Maloney, CPC
    Data Quality Specialist

  7. #7
    Karen read my mind!

  8. #8
    Thanks for your responses. It's always appreciated.

Similar Threads

  1. incomplete exams
    By laura vangroningen in forum Family Practice
    Replies: 0
    Last Post: 11-24-2010, 02:09 PM
  2. incomplete colonoscopy - having a dilemma
    By mitera03 in forum Medical Coding General Discussion
    Replies: 4
    Last Post: 08-25-2010, 10:07 AM
  3. Complete vs. Incomplete
    By ercoder65 in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 08-12-2010, 08:26 AM
  4. operative report/path report
    By codedog in forum Outpatient Facilities
    Replies: 4
    Last Post: 04-09-2010, 07:47 AM
  5. Incomplete Documentation
    By Shelly7169 in forum E/M
    Replies: 0
    Last Post: 04-06-2009, 06:31 PM

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?


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.