Results 1 to 7 of 7

coding a PX W/O documentation, ie 25600

  1. Default coding a PX W/O documentation, ie 25600
    Exam Training Packages
    Does anyone have a supporting documentaion link that states the physcian needs to document all surgeries, even if it is a closed reduction ( Treatment) of distal radial FX? I have a doctor that wants me to bill this without documenting it. He did a brief inpatient consult (99251) and stated he applied the patient in a cast and to F/U with him in four weeks. To me, the consult should be coded and the cast only. Where is the information for me to code the closed reduction (25600)? His response was I should be able to determine what he did by looking at the DX from the xray report.
    I don't know about you, but the way I was trained, if it is not documented, it never happened.

  2. #2
    Dane County - WI
    I agree with you - If it's not documented, it wasn't done.

    If an audit were to be done, they would ask where the documentation was to support the closed reduction. They would not expect it to be assumed from the x-ray report.

  3. #3
    Austin, Texas
    Goodmorning! in the E&M Coding and Documentation Guide--2002 each encounter note for each individual date of service is a stand-alone entry, the medical chart notes for a given date of service must substantiate all services billed for that date, including the level of E/M service, as well as the medical necessity for the service. If the stand-alone entry for a specific date does not support the codes submitted for payment, the service may be considered "under documented/overcoded" on review or audit. Hope this helps!


  4. Default Reply to KatieGal and Sdomel
    Thanks KatieGal and Sdomel. Now I don't feel like I'm loosing it!

    Does anyone else have the link or the site that supports this? I would like to give this to the physcian so he would not think i'm am just making all of this up. Thanks again!

  5. Default
    I also agree. If it's not documented, he didn't do it and cannot bill.
    Look at CMS or AMA websites and even look at the front of the CPT book under instructions for the Use of the CPT Cookbook.

  6. Default correction
    CPT BOOK not cookbook.....Is it Friday yet!

  7. #7
    Milwaukee WI
    Default I feel your pain
    I feel your pain, and you gave me a bit of a laugh, too.

    I knew a surgeon who would sometimes say, "Well, it goes without saying that I did ..." I would respond that "It doesn't go without saying."

    He doesn't have to dictate an entirely separate op report. How hard is it to say, "Performed closed reduction." Just 3 more words! For a LOT more payment.

    S I G H

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. 25622 and or 25600
    By ahinman in forum Emergency Department
    Replies: 5
    Last Post: 10-24-2013, 12:30 PM
  2. Coding without documentation
    By carol52 in forum Medical Coding General Discussion
    Replies: 4
    Last Post: 02-22-2012, 10:54 AM
  3. 25622 and/or 25600
    By ahinman in forum Orthopaedics
    Replies: 1
    Last Post: 08-31-2010, 01:39 PM
  4. coding a PX W/O doucumentation (25600)
    By Trendale in forum E/M
    Replies: 1
    Last Post: 04-08-2009, 12:39 PM
  5. Coding Documentation
    By MREED in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 07-22-2008, 11:50 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?


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.