Trendale
Guest
Hello,
Does anyone have a supporting documentaion link that states the physcian needs to document all surgeries, even if it is a closed reduction ( Treatment) of distal radial FX? I have a doctor that wants me to bill this without documenting it. He did a brief inpatient consult (99251) and stated he applied the patient in a cast and to F/U with him in four weeks. To me, the consult should be coded and the cast only. Where is the information for me to code the closed reduction (25600)? His response was I should be able to determine what he did by looking at the DX from the xray report.
I don't know about you, but the way I was trained, if it is not documented, it never happened.
Thanks!
Does anyone have a supporting documentaion link that states the physcian needs to document all surgeries, even if it is a closed reduction ( Treatment) of distal radial FX? I have a doctor that wants me to bill this without documenting it. He did a brief inpatient consult (99251) and stated he applied the patient in a cast and to F/U with him in four weeks. To me, the consult should be coded and the cast only. Where is the information for me to code the closed reduction (25600)? His response was I should be able to determine what he did by looking at the DX from the xray report.
I don't know about you, but the way I was trained, if it is not documented, it never happened.
Thanks!