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Documentation problem...

  1. #1
    Question Documentation problem...
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    I'm finding it difficult to justify billing some small office surgeries for one of my providers. I'd love others opinions on whether there is enough documentation in these notes to bill a procedure and also, if anyone knows where I could find something in writing that explains documentation guidelines for surgical procedures, that would be truly helpful! Below are two examples. What I've shown is the complete note other than vital signs and medication list.

    Reason for appointment: Ingrown toenail for 1 month.
    Exam: Erythema laterally, edema also. Nail is fractured.
    Impression: ingrown left great toe nail.
    Plan: Avulse.

    Reason for appointment: Elective Vasectomy
    Exam: Bilateral vasectomy done.
    Impression: Elective sterilization.

    Thanks for any help!!

    V. Davis, CPC, CGIC

  2. #2
    Milwaukee WI
    Default Definitely a documentation problem
    I cannot code a procedure for either of these "complete" notes.

    An operative / procedure note needs to have:
    Patient identifiers (obviously you wouldn't post that here)
    Date of service
    Preoperative diagnosis
    Postoperative diagnosis
    if different
    Title of procedure
    Description of procedure performed
    - location and type of incision, instrumentation, findings, closure, etc
    Anesthesia / analgesia used
    Blood loss

    Condition/disposition of patient at end of procedure
    Name and signature of provider

    Hope that helps.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 10-27-2010 at 01:58 PM.

  3. #3
    Thanks! My issue is with compliance with these notes. It's nice to have some confirmation that my concerns are justified.

    I would still be interested in having something in writing to show this provider that more documentation needs to be done. I've only been able to find facility-specific policies and, as far as I know, we don't have any here.

    V. Davis, CPC, CGIC

  4. Default
    Agree w/ FTessaBartels
    Regarding both - the plan/impression is to avulse/sterilize - doesn't say they actually did it. something could have come up and they didn't carry out the procedure that day (ie: pt or provider didn't have time).

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