Wiki Colonoscopy reporting

[dpumford]

Hello: I am looking for documentation guidelines to see if the dication is correct on how this provider dictates this procedure.

I do not code from the "Procedure Heading", Colonoscoy with hot bx forecpts 2x and snare x1

The technique for removing the polps should be included in the body of the report, correct??

What this provider does is states ie: Findings were as noted above...He talks about was the exam reveals, and the total cecum is visulized etc but does not go into detail about the removal of the polps, just states Findings were as noted above.

Is this acceptable? I have searched but can not find any quidelines.. He will need proof if to ask him to change his format...

Any info or insite on this would be helpful

 

[nsteinhauser]

Interesting. I thought documentation supporting this from CMS, OIG, AMA, JCAHO, etc. would be easy to find. Not so. JCAHO has medical record documentation requirements that say "a full description of the procedure" and "specimens removed" but it doesn't specify "instrumentation used" in the requirements for the op note. Anyone else?

 

[Kisalyn]

I have not run across anything in writing that spells out formatting in op notes. Everything I've seen are recommendations. The information focuses on what needs to be included, but not how it should be organized.

We used to have one physician who would dictate the whole of his report under the procedure heading. Habits were very hard to break with him. As long as the info we needed was there, we billed it out.

If a procedure heading stated "Colonoscopy with bx" I see that as a wishlist or what was scheduled and is defintely not billable. Now, "Colonoscopy with cold snare performed on polyp at the ascending colon" gives me enough to code it.

You can show him the NCCI guidelines where it specifically states you can only bill multiple techniques if they're performed in different anatomical sites. If he's not willing to break up the information, at least he needs to make the information usable for you.

In regards to formatting, well, some organizations have compliance manuals. If you're set on a particular format, maybe look into developing one so that all your physicians are on the same page.

If anyone can provide info on formatting, I'd be especially interested.