Results 1 to 2 of 2

Operative Notes

  1. Default Operative Notes
    Medical Coding Books
    Hey everyone!!

    Can someone direct me to a website or article that explains specifically what a physician needs to dictate in his operative report when doing multiple shoulder surgeries. For example, the physicians are dictating "a subacromial decompression was performed". That is not enough. Same for "distal clavicle excision" (29824), "debridement of labral tear" (29823).

    Second question. When the physician does a debridement of labral tear (Type 1) is it billable with 29827 and 29826? If it is, do I use modifier 51 or 59?. Do they have to dictate that they debrided anteriorly and posteriorly? I read somewhere that the labral debridement was included in the 29826.

    Sorry for so many questions - I am just trying to maximize reimbursement but also want to be sure the dictations are appropriate.

    THANK YOU!!!

    Denise

  2. #2
    Default
    Quote Originally Posted by Desperate Denise View Post
    Hey everyone!!

    Can someone direct me to a website or article that explains specifically what a physician needs to dictate in his operative report when doing multiple shoulder surgeries. For example, the physicians are dictating "a subacromial decompression was performed". That is not enough. Same for "distal clavicle excision" (29824), "debridement of labral tear" (29823).

    Second question. When the physician does a debridement of labral tear (Type 1) is it billable with 29827 and 29826? If it is, do I use modifier 51 or 59?. Do they have to dictate that they debrided anteriorly and posteriorly? I read somewhere that the labral debridement was included in the 29826.

    Sorry for so many questions - I am just trying to maximize reimbursement but also want to be sure the dictations are appropriate.

    THANK YOU!!!

    Denise
    http://depts.washington.edu/uwpsite/...s/001sdbs.html

    I was given this link by one of our forum members in reference to this same question, I found it helpful.

    documentation requires a DESCRIPTION of the procedure...not the name of the procedure..no he cannot say "subacromial decompression" (in body of op) he must describe everthing he did to achieve this procedure. I also know for a distal clavicle excision he must state at least 8-10 mm or 1cm of the clavicle was resected....I have been denied on both of these in the past for insufficient documentation. Remember when you were in school and your math teacher said "show your work" ....same principle.

    You can charge for labral debridement so long as it is in different "area" of shoulder...the 29826 is extra-articular work so the 29822 can be used since it was done inside of the joint.

    Keep in mind i have not read the op report.
    There are several AAOS articles regarding the labral debridement, and distal clavicle documentation......if you dont have access ...you can send me email....i will look them up.

    hope it helps!

Similar Threads

  1. Doctor Notes Vs Nurse Notes
    By SJones52 in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 04-04-2012, 03:43 PM
  2. addendum to operative notes
    By com107 in forum General Surgery
    Replies: 1
    Last Post: 11-09-2011, 01:41 PM
  3. Electronic Notes WITH handwritten notes
    By Debbie C in forum Auditing General Discussion
    Replies: 1
    Last Post: 06-29-2010, 10:33 PM
  4. coding from operative notes
    By jhcpc09 in forum Medical Coding General Discussion
    Replies: 4
    Last Post: 06-09-2009, 06:50 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.