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Use This Tool to Capture All of Your Integumentary Services
Published on Thu Jan 06, 2005
Watch what a difference the site and repair details can make
The concept of good, thorough documentation is not foreign to any of you dermatology coders out there. But sometimes, it's easy to overlook the obvious.
Use this tool to help you start looking at the details of only a couple of dermatology practices. Then customize the tool to your own practice by adding details for the most common procedures your dermatologists perform.
Purpose
Your dermatology practice will use the documentation provided in medical for several reasons including:
Details of the care provided to the patient
Origin of charges
Diagnosis and procedure codes
Evidence for appeal claims, if necessary
Utilization and quality-of-care management reviews Necessary Clinical Details (by Procedure)
For wound repair codes (12001-13160), your documentation should include:
Wound dimensions
Anatomic site of each wound
Surgical method used for each wound including:
adhesive strip application in combination with other material or as a sole material
chemical or electrocauterization
debridement
simple repair
layer closure
complex repair (e.g., includes wounds that require extensive undermining)
secondary wound repair
blood vessel, tendon, nerve repair
ligation and/or exploration of vessels
adjacent tissue transfer/rearrangement
split-thickness skin graft
full-thickness skin graft For injection procedures, your documentation should include:
Reason for injections(s):
therapeutic
prophylactic
diagnostic
Site of injections(s):
abscess
cyst
flap/graft
ganglion cyst
intralesional
Substance used for injections(s):
alcohol
anesthetic
lytic solution
medication
pharmacologic agent
steroid
subcutaneous filling material
Injection dose. Editor's note: Material in this tool reviewed by William J. Conner, MD, founder of Conner Health Clinic, a multispecialty practice in Charlotte, N.C.