Wiki help on understanding documentation needed in a drs note for a follow up

Create Wiki Sort by votes
M

mommartin3

New
Messages
2
Best answers
0
Can someone please help me understand what ias needed in a drs note when some one goes to see a orthopedic office for a follow up or just a check up before the surgery? I am confused because I am hearing mixed things and then insurance is denying the visit for documentation don't support the cpt code used. If anyone has a helpful website or anything more on the E/M tools or a outline of what needs to be included in the drs notes it would be greatly appreciated.
 
1
If the provider has already made the decision for surgery and the patient has been scheduled, any visits prior to the case that are just for a "check in" or H&P are included in the global surgical package and not payable as an office outpatient E/M. It doesn't matter when the decision was made. For example, the patient has knee OA and needs a TKA. The provider sees the patient today and schedules the surgery yet they are booked very far out (let's say 2 months). The patient comes in a week before the surgery to "check-in" with no changes, no problems, everything is the same and the surgery goes on as planned. The "check-in" is not billable as they had already decided on and booked the TKA at the prior visit. Another example would be if the provider does a quick H&P (required by the hospital) before admitting the patient for the scheduled, elective surgery. The provider can't bill for the H&P. However, some E/M may certainly be billable beforehand, especially if something changes health-wise or the patient is being seen for an unrelated problem.

When you talk about follow-ups, that depends too. Is it a follow-up post surgically for a surgical procedure still in the global? Is it a follow up for a problem that is not in a global?

There are many different scenarios on follow-ups and pre-surgical appointments. It is difficult to give you yes/no, black/white answer. There is no one size fits all approach for this. Each visit must be coded according to the documentation and the specifics of the encounter. Basic medical record documentation standards would apply in all cases.

If you are new, it may be helpful to find assistance from a more senior coder or supervisor in your practice. The E/M and documentation guidelines apply. If you have a specific example, we can try to help you here.
It also depends on what was billed and documented. If the payer is denying the E/M level it needs to be reviewed 1. to see if it even meets the definition of an E/M, and 2. if it was up-coded. 3. there could be any number of other problems. Do you have a specific example?

Some resources: https://www.aaos.org/quality/coding-and-reimbursement/coding-community/
 
0
Momartin
I d code this as what problem is the patient coming for future surgery. I d use the definitive dx first on claim and then dx Z01.818.If it is a follow up or aftercare surgery check up for checking see how patient doing in which provider should list this in documentation. I would use dx Z09 Follow up or encounter code Z13 block or Z48 blocks as 2nd dx. Put the major illness problem first why original sought treatment.....from provider s notations.
I hope helped you
Lady T
 
Last edited:
You must log in or register to reply here.
Top