KellyLR
Expert
I need some help. I recently started coding for a practice involved in orthopaedics for our coding and billing service. Most of the providers are fantastic with their documentation. However,
there are a couple of docs who dictate ops and after they are transcribed, they include everything that they do in surgery in detail, but they never say what procedure they performed. I am having a tough time with the terminology and discerning what procedure they actually did. I try to compare the op reports with the other surgeons and that helps, but what would one of you do in this situation? Politely ask the surgeon to dictate in their notes the type of surgery he did. I'm at a loss to figure out how the other coder before me handled this being that this practice is so new to our business and we don't get the liberty to review older records right now. I feel uncomfortable about reading the report and extracting all the elements and then deciding what procedure the doc performed. I have been burning the midnight juice to educate myself quickly concerning Musculoskeletal and its mechanical properties but i never thought about anesthesia, hip traction for two hours then perform a procedure/revision/reconstruction but not total hip replacement or implant for one side and then do the same for the other! This one doc describes how he removes burrs and stuff from the acetabular. This is kicking my butt!
Please help, anything would be appreciate in how to approach this matter.
Please help, anything would be appreciate in how to approach this matter.
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