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REQUIRED ELEMENTS for common procedure in PED ED

  1. #1
    Default REQUIRED ELEMENTS for common procedure in PED ED
    Medical Coding Books
    Hi ALL,
    I would like to develop acronym expansions for specific procedures that the MDs do very often, but do NOT already have templates, so they are much less likely to ever document (huge source of lost income).

    For the following procedures, could you tell me:
    1. What are the REQUIRED ELEMENTS that constitute a complete note for the specific procedure
    2. What is the range of $$$ that you can earn (i.e. lowest amount, and highest amount) for each procedure.

    Hopefully this will improve AND increase documentation of procedures in a way that satisfies documentation properly, for billable procedures that are done ALL THE TIME
    I am doing billing for EDMD.


    These are the procedures:

    1. Cerumen/ear wax removal
    2. Foreign body removal
    3. Splinting/ACE bandage application/sling application
    4. Abrasion cleaning
    5. Fluoroscein staining (for corneal abrasions)
    6. IV cannulation

    Wioletta

  2. #2
    Default
    Quote Originally Posted by kviolet View Post
    Hi ALL,
    I would like to develop acronym expansions for specific procedures that the MDs do very often, but do NOT already have templates, so they are much less likely to ever document (huge source of lost income).

    For the following procedures, could you tell me:
    1. What are the REQUIRED ELEMENTS that constitute a complete note for the specific procedure
    2. What is the range of $$$ that you can earn (i.e. lowest amount, and highest amount) for each procedure.

    Hopefully this will improve AND increase documentation of procedures in a way that satisfies documentation properly, for billable procedures that are done ALL THE TIME
    I am doing billing for EDMD.


    These are the procedures:

    1. Cerumen/ear wax removal
    2. Foreign body removal
    3. Splinting/ACE bandage application/sling application
    4. Abrasion cleaning
    5. Fluoroscein staining (for corneal abrasions)
    6. IV cannulation

    Wioletta
    Most of these items require more documentation that just the procedure name, to qualify for reimbursement (location, technique/instrumentation used, etc.) - I wouldn't recommend making a short-cut for them; otherwise, they may develop a false sense of security, thinking that they've documented enough, when all they really have is a vague reference to what they did. The only thing on here I've seen a common abbreviation for is 'foreign body' (=FB). As for the rest, if they want to get paid, they need to take the time to adequately document the details of what they did. Sorry...
    Last edited by btadlock1; 02-05-2012 at 01:03 PM.

  3. #3
    Location
    Columbia, MO
    Posts
    12,959
    Default
    I am in agreement with Brandi. One of the issues being looked at this year by the OIG is "cloned" documentation. I know the temptation is there to create templates for everything but I advise against it.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Location
    Swainsboro/Statesboro
    Posts
    673
    Default
    I agree with the girls...and since the ER is case by case, documentation will be needed for each patient....
    Susan Edwards, CPC, CEDC, AAPC Fellow
    Swainsboro/Statesboro Georgia President

    smecoder@gmail.com

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