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Thread: coding a PX W/O documentation, ie 25600

  1. #1

    Default coding a PX W/O documentation, ie 25600

    AAPC: Back to School
    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
    Join Date
    Apr 2007
    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
    Join Date
    Apr 2007
    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. #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. #5


    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. #6

    Default correction

    CPT BOOK not cookbook.....Is it Friday yet!

  7. #7
    Join Date
    Apr 2007
    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

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