Wiki Opinion if wording should be changed

[AN2114]

The doctor said he did a bilateral myringotomy with tympanostomy tube placement. I wanted to get an opinion about the bold line in the following op report:

The right ear was initially examined using the operating microscope. Cerumen was removed with a curette. Using a myringotomy knife, an incision was made in the anterior inferior quadrant. Subsequently, a #5 suction was used and scant serous fluid was aspirated. A Sheehy tube was then placed with aid of alligator forceps and ciprodex drops were administered. Attention was then turned to the left ear where a similar procedure was performed and mucoid fluid was aspirated.

So based on that wording, would you just bill this bilateral? Or would you have the doctor update the report and say attention was then turned to the left ear where a similar procedure was performed and mucoid fluid was aspirated and tube placed? Maybe I just overthink things but based on that wording I didn't know if insurance would view it as it was a similar procedure in that fluid was aspirated in both ears and the tube was in one ear so they would want more detail. I have a couple op reports worded just like this so I wanted opinions if you think the above info is sufficient to bill bilateral tube insertion or have the doctor fix the wording.

 

[kimberlywatson]

I see this often for simple/uncomplicated bilateral procedures. Of course it's always best practice for the provider to document the details for both sides, but I'd say in this case it's ok. Another option is to query the provider and confirm it truly was the same procedure on each side. Let him/her know that the documentation could be misleading. You can use this as an education opportunity to let them know what you need as a coder to be confident in your code selection.

Hope that helps!

 

[AN2114]

I see this often for simple/uncomplicated bilateral procedures. Of course it's always best practice for the provider to document the details for both sides, but I'd say in this case it's ok. Another option is to query the provider and confirm it truly was the same procedure on each side. Let him/her know that the documentation could be misleading. You can use this as an education opportunity to let them know what you need as a coder to be confident in your code selection.

Hope that helps!

Thank you!