CJoy0724
Networker
Does anyone have documentation guidelines for procedures being done bilaterally? We have a provider who performed a bilateral total hip replacement, and instead of documenting each side separately he added this to the beginning of the body of the note:
"The remainder of the operative dictation is accurate for the left hip. Once the left hip was completed we then proceeded to perform the right hip. The procedure reads the same for both hips."
Is this acceptable? My gut says no, but I cannot find anything either way. He does state bilateral at the top, discusses both hips in the operative indications, and lists the implants separately.
"The remainder of the operative dictation is accurate for the left hip. Once the left hip was completed we then proceeded to perform the right hip. The procedure reads the same for both hips."
Is this acceptable? My gut says no, but I cannot find anything either way. He does state bilateral at the top, discusses both hips in the operative indications, and lists the implants separately.