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Lisa Bledsoe

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note reads:
Reason for visit: Injection: B Supartz: Patient returns today for scheduled viscosupplement injection.
Assessment and Plan: The knee(s) was/were sterilly prepped in the usual fashion. Using sterile technique, the viscosupplement was administered. The patient tolerated this injection well. She will return in one week for the next injection.

Now, am I being too picky or would this be clear to anyone that the patient had both knees injected with Supartz? My opinion is that insurance would say it is not clear that both were injected. I don't think it supports both knees because it is too vague...

(I know that is what the patient had done, but how many corners can EMR cut?)
 
Lisa Curtis said:
note reads:
Reason for visit: Injection: B Supartz: Patient returns today for scheduled viscosupplement injection.
Assessment and Plan: The knee(s) was/were sterilly prepped in the usual fashion. Using sterile technique, the viscosupplement was administered. The patient tolerated this injection well. She will return in one week for the next injection.

Now, am I being too picky or would this be clear to anyone that the patient had both knees injected with Supartz? My opinion is that insurance would say it is not clear that both were injected. I don't think it supports both knees because it is too vague...

(I know that is what the patient had done, but how many corners can EMR cut?)
Click to expand...

I agree, Lisa. Since knee(s) was/were could be singular or plural, it would be hard to prove that both were injected. Not to mention that the last word "injection" is in singular form.
 
I still agree that it's still too vague; but I suppose one could argue differently.One of our providers was recently dinged on an outside audit for a similar statement. As a whole, I don't think it's a clear, precise statement. Is this a templated statement?
 
This does look a lot like a template and the person editing did not edit that part. I would have the physician correct in your system by creating an addendum to cover both the billing and the patient-should any problems arise. :)
 
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