Wiki Manipulation

[KoBee]

If a provider is a using CPT 25605, isn't there suppose to be some sort of procedure note to describe the manipulation? I have a provider who is only stating " manipulation " in assessment and plan. But there is no procedure note. Can someone please advice and also share some procedure notes when doing manipulation in an office setting. Greatly appreciate it.

 

[Orthocoderpgu]

I don't have a ready example of manipulation right off hand but I have coded hundreds of these over the years. Frequently the documentation includes the type of anesthesia and how much was given. What forces were applied (volar, dorsal...) and if the bones were able to be brought back into anatomical alignment. After the bones are put back into alignment the physician applies a cast or splint to hold it in place. All of this should be documented. Just stating "manipulation" is not sufficient to support billing the code. You may want to remind your physician that these are legal documents which could come back to haunt them if they are not specific enough in their documentation to prove what was done.

The physician should also document if the patient tolerated the procedure well or not. Most of the time they do, but I have seen cases where the patient was not able to tolerate the procedure.