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Wiki Documentation requirements for bilateral procedures

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efredette

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Does anyone have a reference for documentation requirements for symmetric procedures? We've searched high and low and cannot find a good source. We're trying to determine if the provider is documenting sufficiently. Any help would be appreciated!
 
I do not know of any "official" sources that specifically address bilateral procedures. There are official sources for medical record documentation, such as:

The Joint Commission: https://foh.psc.gov/tjc/roc/standards.pdf (page 14 for operative reports)
Medicare Conditions of Participation for Hospitals: https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/pdf/CFR-2011-title42-vol5-sec482-24.pdf​

But these "official" sources do not specifically address what is required when documenting a bilateral procedure. In my experience, a physician statement that the procedure was performed on the opposite (contralateral) side in the same manner/fashion as the first side has been sufficient and I have never had an insurance carrier deny reimbursement for bilateral procedures with that type of statement. Having said that, if the second side was not done in EXACTLY the same manner/fashion as the first side, then specific documentation as to how it was done differently would be required.

AHIMA has a clinical example in one of their training texts that supports this type of documentation, which is the closest I have found to any "official" source (http://www.ahima.org/~/media/AHIMA/Files/AHIMA-Press/2011AppendixAUpdates.ashx) (pages 29-30):

Operative Report

Preoperative Diagnosis: Thrombosed hemorrhoids
Postoperative Diagnosis: Same

Indications: This 25-year-old female, one week postpartum, complains of extremely painful hemorrhoids. Examination revealed circumferential prolapsed hemorrhoids with partial thrombosis in multiple areas.
Procedure: After induction of general anesthesia, she was prepped and draped in the usual sterile fashion. The patient was placed in lithotomy position and a retractor was placed in the anus. Very prominent, large, partially thrombosed external hemorrhoid was identified at 7-8 o'clock in the lithotomy position. It was grasped with a hemorrhoidal clamp. A 2-0 chromic stitch was placed at the apex. The Bovie electrocautery was then used to elliptically excise the large hemorrhoid, staying superficial to the sphincter muscle. Bleeding was controlled with Bovie electrocautery. The mucosa was closed with a running chromic stitch, leaving the end-point epidermis open.

Two other very large external hemorrhoids with thrombosis were then identified, at the 5 o'clock position in lithotomy and at the 10-11 o'clock position. These two hemorrhoids were excised in the exact same fashion as the first hemorrhoid. At the conclusion, there was no evidence of bleeding. The patient was returned to the recovery area in good condition.

Abstract from Documentation:
What method was used to remove the hemorrhoids?
Excision

Where the hemorrhoids internal or external?
External

How many columns or groups were documented?
3

Time to Code:
Index:
Hemorrhoid, Excision

Code(s):
46250 Hemorrhoidectomy, external, 2 or more columns/groups​

Hope that helps!
 
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