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bilateral

  1. #1
    Location
    Greeley, Colorado
    Posts
    2,045
    Question bilateral
    Medical Coding Books
    note reads:
    Reason for visit: Injection: B Supartz: Patient returns today for scheduled viscosupplement injection.
    Assessment and Plan: The knee(s) was/were sterilly prepped in the usual fashion. Using sterile technique, the viscosupplement was administered. The patient tolerated this injection well. She will return in one week for the next injection.

    Now, am I being too picky or would this be clear to anyone that the patient had both knees injected with Supartz? My opinion is that insurance would say it is not clear that both were injected. I don't think it supports both knees because it is too vague...

    (I know that is what the patient had done, but how many corners can EMR cut?)
    Lisa Bledsoe, CPC, CPMA

  2. #2
    Location
    North Carolina
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    3,126
    Default
    Quote Originally Posted by Lisa Curtis View Post
    note reads:
    Reason for visit: Injection: B Supartz: Patient returns today for scheduled viscosupplement injection.
    Assessment and Plan: The knee(s) was/were sterilly prepped in the usual fashion. Using sterile technique, the viscosupplement was administered. The patient tolerated this injection well. She will return in one week for the next injection.

    Now, am I being too picky or would this be clear to anyone that the patient had both knees injected with Supartz? My opinion is that insurance would say it is not clear that both were injected. I don't think it supports both knees because it is too vague...

    (I know that is what the patient had done, but how many corners can EMR cut?)
    I agree, Lisa. Since knee(s) was/were could be singular or plural, it would be hard to prove that both were injected. Not to mention that the last word "injection" is in singular form.

  3. #3
    Location
    Greeley, Colorado
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    Default
    Thanks Rebecca! What do you think of "B" as bilateral?
    Lisa Bledsoe, CPC, CPMA

  4. #4
    Location
    North Carolina
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    3,126
    Default
    I still agree that it's still too vague; but I suppose one could argue differently.One of our providers was recently dinged on an outside audit for a similar statement. As a whole, I don't think it's a clear, precise statement. Is this a templated statement?

  5. #5
    Default
    This does look a lot like a template and the person editing did not edit that part. I would have the physician correct in your system by creating an addendum to cover both the billing and the patient-should any problems arise.

  6. #6
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    Greeley, Colorado
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    Default
    It is templated...and they never edit!
    Thanks for the input!
    Lisa Bledsoe, CPC, CPMA

  7. #7
    Location
    North Carolina
    Posts
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    Default
    Quote Originally Posted by cpccpma View Post
    This does look a lot like a template and the person editing did not edit that part. I would have the physician correct in your system by creating an addendum to cover both the billing and the patient-should any problems arise.
    I agree...

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