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coding off from a hand written procedure from the procedure doctor

  1. #1
    Default coding off from a hand written procedure from the procedure doctor
    Medical Coding Books
    Can you code from a hand written procedure from the procedure doctor? The procedure does dictated at the hospital when I let him know that he did not dicated the procedure at the hospital.

  2. #2
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    Milwaukee WI
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    Default Procedure documentation
    As long as the procedure is adequately documented, yes, you may code from a handwritten procedure note. "Adequately documented" will include legibility of the note, date of service, clear indication for procedure, clear description of what was done (not just a title), clear indication of who is performing the procedure and the provider's signature and date.

    I have coded a procedure (e.g. laceration repair) when it is only handwritten and not dictated/transcribed.

    BUT ... most hospitals require a dictated operative note for anything requiring anesthesia and/or not done at bedside.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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