Wiki Documentation Question

[ywilliamsCPC]

We cover a lot of cataract surgeries. I'm finding that on the operative reports the surgeons are not dictating the specific type of cataract, however, on the order that we receive from their office the type of cataract is specified. If the anesthesiologist when writing the dx on the anesthesia record, wrote the specific type of cataract could I then use the specified code since it is documented or do I have to go by the operative report only?

 

[Deb P]

Use the specified code...

...and have the surgeon amend the op note. The insurances are going to want the specification. Good luck!

 

[JudyW]

We cover a lot of cataract surgeries. I'm finding that on the operative reports the surgeons are not dictating the specific type of cataract, however, on the order that we receive from their office the type of cataract is specified. If the anesthesiologist when writing the dx on the anesthesia record, wrote the specific type of cataract could I then use the specified code since it is documented or do I have to go by the operative report only?

You can use the dx code on the anesthesia record and hopefully the coders for the surgeon's office are requiring a more specified code from the surgeon.

 

[ywilliamsCPC]

Thanks for your help