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E\M with Surgical Procedures

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    Medical Coding Books
    I really see both sides. I'm looking at the note and in the Impression he will state\list the diagnosis\problems. The next seprate section he will have the Plan with which is what he did\or treatment options to address the diagnosis listed in the Impression.

    For me I look at it and can tell what was done and can code from it. But because its not mentioned in the Exam part of the note how do you know for sure he did it, if he didnt even exam it? I've talked to an Auditor I know and she says that since its a Procedure it just has to been listed somewhere in the note as to what was done.

    On the other hand and I know everyones thoughts on this, and I should have my answer by just this alone but......

    The place I'm working at now was Audited my Medicare ( not for this reason but b\c they were using a code that they really shouldnt have been using which raised a RED flag for Medicare, and this was the only reason for the Audit ) but you know Medicare since they were already here why not take a look to see what else they could find.....thus this problem....Medicare said the same thing that Kevin stated if its not mentioned anywhere in the note how do you really know it was done, just by stating that you did it, but you didnt even look at the site or do you know for sure??? Long story short we lost, and had to give back lot of money!!! ( This was before I got here thank god!!!) Based off of this information alone I should not even waste my time with this right??? But I know from my own experience several of us coders have not applied this to our coding guidelines.

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    The fact that the stage I ulcer was not mentioned in Chief Complaint nor in the Exam would raise a flag for me if this procedure was intended for the patient - could be human error on the part of the physician. I would request a clarification why this procedure was performed in the absence documented of medical necessity, and if it is in fact medically necessary and was agreed upon, an addendum should be submitted.

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