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Procedure documentation?

  1. Default Procedure documentation?
    Medical Coding Books
    I have a new ARNP right out of school who is trying to tell me that the following documentation is adequate for the medical record. I'm telling her no way and I am refusing to bill the procedure codes until I get more information on the procedures. Please give me some input so that I know I have not lost my mind!!!!

    PROCEDURES
    MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING [51798] -- PVRs obtained via bladder scan was ranging 400-600. Planned to catheterize patient.
    Related Diagnosis:
    ICD Code ICD Description
    788.21 INCOMPLETE BLADDER EMPTYING

    URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY [81002] -- All wnL besides urine was dark, pH 6.0, specific gravity 1.020.
    Related Diagnosis:
    ICD Code ICD Description
    788.63 URGENCY OF URINATION

    INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE) [51701] -- Following sterile prodecure, foreskin was retracted, patient was cleansed with betadine and a sterile foley catheter was inserted into his bladder. Foreskin was reduced back into place. PVR obtained was 425 mL immediately after patient has voided.

  2. Default
    I also need to tell you that these procedures were listed like this within the E/M documentation.

    Thanks!

  3. #3
    Location
    Kansas City, MO
    Posts
    431
    Default
    What more are you looking for? These are minor procedures/labs....seems like enough to me.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  4. #4
    Default
    I agree with Linda; I would be ecstatic with this level of documentation for minor procedures. It has been my experience that midlevel providers with a nursing background document well, especially new grads/newly licensed.

    Frankly, I do not care where the procedures are documented, in the E/M, upside down... I worked with a doc many years ago who wrote his orders in the margins of the order sheet requiring the staff to turn the sheet around 360 degrees to obtain all of the info.

  5. Default
    I must agree with the two above.. it seems fine to me. Be lucky in what she/he documents!!! Most do not even do that much!

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