Wiki Documentation problem...

[Torilinne]

I'm finding it difficult to justify billing some small office surgeries for one of my providers. I'd love others opinions on whether there is enough documentation in these notes to bill a procedure and also, if anyone knows where I could find something in writing that explains documentation guidelines for surgical procedures, that would be truly helpful! Below are two examples. What I've shown is the complete note other than vital signs and medication list.

#1:
Reason for appointment: Ingrown toenail for 1 month.
Exam: Erythema laterally, edema also. Nail is fractured.
Impression: ingrown left great toe nail.
Plan: Avulse.

#2:
Reason for appointment: Elective Vasectomy
Exam: Bilateral vasectomy done.
Impression: Elective sterilization.

Thanks for any help!!

V. Davis, CPC, CGIC

 

[FTessaBartels]

Definitely a documentation problem

I cannot code a procedure for either of these "complete" notes.

An operative / procedure note needs to have:
Patient identifiers (obviously you wouldn't post that here)
Date of service
Preoperative diagnosis
Postoperative diagnosis if different
Title of procedure
Description of procedure performed - location and type of incision, instrumentation, findings, closure, etc
Anesthesia / analgesia used
Blood loss
Complications
Condition/disposition of patient at end of procedure
Name and signature of provider

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Torilinne]

Thanks! My issue is with compliance with these notes. It's nice to have some confirmation that my concerns are justified.

I would still be interested in having something in writing to show this provider that more documentation needs to be done. I've only been able to find facility-specific policies and, as far as I know, we don't have any here.

V. Davis, CPC, CGIC

 

[mkm1517]

Agree w/ FTessaBartels
+
Regarding both - the plan/impression is to avulse/sterilize - doesn't say they actually did it. something could have come up and they didn't carry out the procedure that day (ie: pt or provider didn't have time).