Wiki Documentation Issue

Thumper72

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Could anyone tell me if the attached document meets the guidelines for documenting an Orthovisc Injection. I don't feel there is enough information, but I'm also new to billing for Ortho.
 

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  • Orthovisc.pdf
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Personally, I wouldn't use that form as documentation. It doesn't state why the patient is having the procedure, previous treatment, what the approach used was, how many cc's were given of the Orthovisc, etc... My docs used to have a template that they used when they gave Synvisc/Hyalgan but it was a transcribed document. I don't know that any insurance company would accept what you have as documentation. Hope that is helpful!
 
I have to agree, I would not code an injection from this information you need a documented diagnosis not a dx code as many times the code number is incorrect. You need all the information Donna cited in her response as well. Not only will the payer not accept it, as a coder you should not accept it.
 
Agree, this is not sufficient documentation for the procedure, it mearly shows where the injections were done, but does not describe why or provide any documentation for diagnosis.
 
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