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Ob-Gyn Coding Alert

Reader Question:

Boil This Procedure Note Down to What MD Actually Performed

Published on Sat Jan 15, 2011

Question: My ob-gyn documented the following note:Procedures: Administered injection. Patient given one dose of Atropine. Site - Left Upper Quadrant Lot # 0211317 Expiration: 2/2013 Patient given 60mg of Tordol. Site - Left Upper Quadrant Lot@ DK 12011 Expiration: 11/2012. Thermachoice Ablation: Betadine was used to cleanse vaginal vault and cervix. Superficial anterior cervix was injected with 2cc 0.05% Carbocaine (20cc mixed with 20cc Saline=40cc total volume) using a 10cc control syringe with a 22 gauge needle and a needle extender. Anterior cervix was grasped with a single toothed tenaculum. 5cc Carbocaine was injected at 4, 8, 10 and 2 o'clock just medial to the cervico-vaginal reflection. Waited (5) minutes to ensure a complete paracervical block. Cervix was dilated with the Pratt dilators. The 5mm hysteroscope slid into the cervix with ease. General survey revealed normal endometrial cavity. Endometrial biopsy was performed to ensure adequate anesthesia. Two passes were performed [...]
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