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E\M with Surgical Procedures

  1. Default E\M with Surgical Procedures
    Medical Coding Books
    "Podiatry" Example: Pt comes in for treatment of his foot, and toenail debridement. Physican does a exam and in the Exam talks about the toenails. In the Impression again talks about the toenails, and a Stage 1 ulcer. In the Plan he talks about doing the debridement of the toenails and the debridement of the Stage 1 ulcer.

    Question: Can I bill for the debridement of the ulcer (11040) even though it is not mentioned in the exam or anywhere in the note with the exception of the Impression and Plan?????

  2. #2
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    Does he describe the debridement? If the procedure is not described I don't think you can code it.

  3. #3
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    If its not documented, it wasn't done !!

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  4. Default
    It is documented ( depth ) in the Plan and Impression. Its not documented anywhere in the exam part of the note. I'm being told that if its not mentioned in the exam (EM) part of the note and only mentioned in the Plan and Impression then I cant charge for it. On the other hand I've been told that since its a Procedure it only has to be documented as to what was actually done, reguardless if it was not mentioned in the exam. Help!!!!!

  5. #5
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    North Carolina
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    In my humble opinion, I think this is a very gray area without seeing the actual documentation. I, personally, would not feel comfortable with this type of dicatation. Several questions came to mind:

    Was there documentation suporting the level of tissue removed; the method use to debride, and the character of the wound before and after debridement? Are there underlying issues; such as diabetes? In the event of infection, what would one reference to, regarding the previous condition of the wound, if there was no exam notated in the previous visit? If may just be me...but I'm a stickler for documention.
    Last edited by RebeccaWoodward*; 05-01-2008 at 06:05 PM.

  6. Default
    The bottom line is that its stated in the "plan and impression" . From the information in the plan and impression I know what level he went to and the reason (dx) for doing it. This is done in office, the problem is I'm being told that I CAN NOT code for the debridement of the ulcer on the foot b\c it is NOT stated any place in the note\documentation that he even looked at it, with the exception of the plan and impresson. I'm just trying to find out when I bill for office procedures (lesions, debridements, joint injections) how or where does it need to be documented????

  7. #7
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    North Carolina
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    I know this is frustrating...documentation and compliance always is. I have some other resources I can contact. I'm really curious as to what other CPC's and instructors have to say...You presented a very good question. I'll let you know what my "guru's" comments are.

  8. #8
    Location
    Louisville, KY
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    If a provider states in the course of an E/M service record that a procedure was performed then it can be coded.

    However, if there's ambiguity about it "plan to do", "consider" or the like, it would be prudent to simply code an E/M service; you really have no way of proving anything further being performed.

    Providers, too, must be educated on how we (coding and compliance folks) need to see bedside and office procedures written. Although it might seem clear to them that "yes, I debrided the wound," we and the payer side have no way of knowing that outside relying on their records.

    Although it's gray, I'd work internally to set up a uniform system for clinicians and coders.

    Good luck!

  9. #9
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    North Carolina
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    Well stated, Kevin~

  10. #10
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    North Carolina
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    Here's one response I received for your question~

    "That is technically correct. It is generally not a good idea to document procedures in the “plan” section of the note because this usually means that they are documented as a provider's intent to do something, which as I mentioned, counts for zero. But as long as the procedure is documented in the past tense with enough detail to support the code it can technically be documented in the plan, above the history, on the back of the paper, or on a napkin (as long as it has been added to the medical record and contains patient data on it). Enough details to support the code and documented-in-the-past-tense are the important parts.

    Putting a procedure note in the middle of an E/M encounter (within the Exam) is just as unwise as putting it in the plan. It can often lead to the E/M and the procedure appearing as one mixed service, instead of a complete E/M and a separately identifiable procedure.

    Ideally, the full E/M note would be completed, and then be followed by a separate and distinct procedure note written in the past tense that contains enough detail within it to bill the code."

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