Wiki Incomplete op report

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coderguy1939

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Doctor did YAG Capsulotomy,66821, but did not include total engery, exposures, etc. on the report. A query was sent to the doctor's office and came back stating "information not available". The doctor did the procedure, but this is an incomplete report. I'm coding for the facility side. Can this be coded with an internal billing note indicating that the deficient info was requested but not available? Thanks for your input.
 
I guess my question is WHY isn't this information available? I realize the procedure was performed, but if the op note wasn't "complete" then I don't see how the physician or facility could bill for it appropriately....until it is complete.

Anyone else?!
 
I code for an ASC. These procedures were performed in 06/2008 and I can only assume the information is not available because it wasn't dictated at the time it was performed and the doctor cannot recollect the specifics. The doctor uses a op report form that he fills out by hand and he indicated Capsulotomy and gave an appropriate DX, but omitted the info referenced above which is typically included.
 
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I figured! This is why documentation at the time of service is sooooooo important. No late entries! I would probably go ahead and bill it anyway, the procedure WAS performed, you have some documentation, that could be your argument. Does the payer require you have the information that you are missing?
 
Thanks, I was just wondering because I codeAmb Surg in a hospital setting.
For the procedure you describe, I don't have to have the info you are missing to code the procedure.
 
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