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Thread: Documentation requirements for physicians

  1. #1

    Default Documentation requirements for physicians

    AAPC: Back to School

    I was hoping someone could let me know where I would find the requirements for documenting surgery. We have some physicians saying it is unnecessary to dictate a procedure note for minor surgery (debridement, I&D) as long as there is a signed surgery form saying what procedure was done. I want to be sure we are compliant and show them the rules. Any ideas? I've tried the CMS website, but it is soooooooo hard to navigate.

    Thank you

  2. #2


    In my experience, if it was not documented it did not happen. I do not think that the signed consent form is enough documentation to prove that a procedure was done, no matter how minor. If the physicians want to get paid for their work, then they should document.

  3. #3
    Join Date
    Apr 2007
    Greeley, Colorado


    Absolutely - if there is not documentation from the doctor describing the procedure, then it can't be billed. Documentation MUST support the reported code(s).

  4. #4


    You should be able to find cites regarding documentation for the topics of interest in your carrier's website. Check for local coverage determinations (LCD) and bulletins or articles. If you're using the CMS website, look under the Medicare coverage database and perhaps you will find articles or LCDs for your geographic region. I know for the carrier that I use, there is an LCD on debridement. Also, let your providers know that if an external auditor gets a hold of the medical records, they could be in for some costly problems if they don't document clearly and completely.

  5. #5
    Join Date
    Apr 2007
    St. Louis, Missouri


    How could you code a debridement or I&D without a procedure note? You need to know how deep the debridement was in order to choose the correct code. With an I&D you also need to know the depth. If it goes down into the fascia then you can go into the musculoskeletan section of the CPT book. If it was not that deep, you still need to know if it was packed or a drain was put in. If either of these were done, then you can code a complicated I&D in the Integumentary System section of the CPT book. It seems to me that your practice may be losing money if you have to code without this information.

    Melissa Blow, CPC

  6. #6
    Join Date
    Apr 2007
    Chicago South East Illinois Chapter

    Thumbs up Documentation Requirements


    I'm a Professional Fee Billing Administrator for one of the largest Medical Center's Dept. of Surgery here in Chicago. I instruct my coders that if it's not documented for them to review & verify "Don't Bill It"! Determination of CPT codes is based on physician documentation not coders assumptons. You need to know how many cm or how extensive the I & D was. It sounds like cpt code choices are being made just on doctors say so. Your doctors need to dictate a procedure note even if it was a minor procedure to be compliant whether a local was used or anesthesia for billing purposes. A note in a patient's chart or shadow file is mandated anyway. If they get a visit from JCAHO and your docs are audited, they'll wish they took the time to dictate a note. Trust me from experience the Joint Commission pops in on anybody at anytime. You can find documentation requirements on your WPS Local Coverage website. Good Luck........

    Dbryant, M.A.,CPC

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