Wiki Ear Lavage

[KoBee]

Are the simple words " ear lavage performed " enough documentation to support CPT 69209? I was looking for a more specific detail procedure note. But I have providers who feel that's enough but I don't or i can be wrong.

 

[Orthocoderpgu]

Are the simple words " ear lavage performed " enough documentation to support CPT 69209? I was looking for a more specific detail procedure note. But I have providers who feel that's enough but I don't or i can be wrong.

Why are you selling yourself short? Keep in mind that the documentation must support the codes submitted. Think of it this way. Can you put the documentation in front of another coder who does not work in your clinic and does not know the providers and have them pick out the same codes? If not, the documentation is lacking. Which ear or ears? Instrumentation used? If so, what specific instrumentation? If no instrumentation, what was used? Was it successful? Was anything abnormal found? Just documenting "lavage performed" is so lacking in information that there is no way to properly choose a code.