Wiki Aspiration procedure documentation

[IRISHCODER]

I need an opinion on whether or not this is acceptable for a procedure note before we bill this charge. I say it isn't. Our surgeon performed a knee aspiration and this is what the electronic record from the hospital says:

Operative Information
Pre-Op Diagnosis: cellulitis, abcess right knee.
Post-Op Diagnosis: Same as Pre-Operative Diagnosis.
Procedure :needle aspiration right knee abscess.
Surgeon(s): XXXX XXXX
Anesthesia: Local
Specimens: Cultures
Wound Type: Clean
Drains: None
Complications: None
Estimated Blood Loss: None
Patient Condition: Stable

Signature Line
(Electronically Signed By
__________________________________
MD XXXX XXXXX

I always look for a complete procedure note, even for an aspiration. Others have a differing opinion. I'm holding off on billing for now. Any input is appreciated. Thanks!

 

[MarcusM]

I would say it lacks specific documentation to support the procedure. How much fluid was aspirated? Color of aspirated fluid? Was fluid sent off? Was mobility improved post procedure? etc.