Wiki Procedure note documentation

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maryir

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Hello - One of the surgeons in the office is insisting the information he submitted is sufficient documentation to support charging for CPT's 29325, 27502. I'm saying it's not enough for the fracture care. Please see below and give me your opinion. Also, if you have any guideline to support your opinion, I'd appreciate that as well.

Thanks

This is the complete note:
The patient was transferred to an operative table, underwent induction of anesthesia and placement of breathing tube, was positioned supine on the spica table.

A timeout was held.

The goretex and webril was applied with help of the cast technicians. Fluoroscopy was obtained to confirm adequacy of alignment. The casting was applied, and a gentle mold was applied in the thigh to maintain the alignment. Fluoroscopy confirmed the alignment again. The cast was then modified for any zone of prominence or wrinkles, edges padded and then finalized with an overwrap and tape for the goretex liner. The spica was a 1.5 leg spica style.
 
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maryir said:
The issue, as I see it, is that the surgeon DID NOT document sufficiently for the fracture care. The note I posted is the surgeons complete note.
I'm asking for other views on whether what he documented is enough to charge fracture care as I don't think it is ( I would remove the charge).
If he would add additional documentation (currently he doesn't feel he should), then I would reevaluate the codes submitted.
Click to expand...
Now I understand. For the reduction of the fracture, the provider needs to identify the fracture, site and laterality. None of that is included. The provider then needs to describe the manipulation process which brought the bones back into alignment. Just stating that the alignment was visualized or confirmed with fluro is not enough.

After the bone was manipulated back into position a cast was placed to keep the fracture in place. Casting is always included with any kind of fracture reduction. So no matter what is documented you can't bill 29325.

I'm with Amy, you don't have enough documentation to bill anything at this point.

When I help people here I don't just "give" someone the answer. That does not develop them as a coder. I try to help coders to get to the correct answer. That way they can apply what they learn to other scenarios.

Your provider is documenting in a way that only someone who was a medical professional and in the OR would understand what they did. Providers need to document so everyone can understand even if they were not in the OR room at the time.
 
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maryir said:
Hello - One of the surgeons in the office is insisting the information he submitted is sufficient documentation to support charging for CPT's 29325, 27502. I'm saying it's not enough for the fracture care. Please see below and give me your opinion. Also, if you have any guideline to support your opinion, I'd appreciate that as well.

Thanks

This is the complete note:
The patient was transferred to an operative table, underwent induction of anesthesia and placement of breathing tube, was positioned supine on the spica table.

A timeout was held.

The goretex and webril was applied with help of the cast technicians. Fluoroscopy was obtained to confirm adequacy of alignment. The casting was applied, and a gentle mold was applied in the thigh to maintain the alignment. Fluoroscopy confirmed the alignment again. The cast was then modified for any zone of prominence or wrinkles, edges padded and then finalized with an overwrap and tape for the goretex liner. The spica was a 1.5 leg spica style.
Click to expand...
What is your assessment or thoughts other than you don't think it's enough for fracture care? The two codes provided do hit an edit, so would you bill both codes or would you consider one bundled?
 
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Orthocoderpgu said:
What is your assessment or thoughts other than you don't think it's enough for fracture care? The two codes provided do hit an edit, so would you bill both codes or would you consider one bundled?
Click to expand...
Depends on what he documents. Know there's a CCI edit but can't evaluate until I have the complete documentation.
Still looking for guidance regarding documentation of fracture care.
 
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maryir said:
Depends on what he documents. Know there's a CCI edit but can't evaluate until I have the complete documentation.
Still looking for guidance regarding documentation of fracture care.
Click to expand...
I'm confused. In your initial posting you state that "This is the complete note" Now your saying that you can't evaluate this until you have the complete documentation. Is the provider going to add or modify the existing documentation?
 
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The issue, as I see it, is that the surgeon DID NOT document sufficiently for the fracture care. The note I posted is the surgeons complete note.
I'm asking for other views on whether what he documented is enough to charge fracture care as I don't think it is ( I would remove the charge).
If he would add additional documentation (currently he doesn't feel he should), then I would reevaluate the codes submitted.
 
0
Is that really all the documentation of the entire encounter? Is this a hospital note/ED/obs/office procedure note? I can't believe that this is really the whole documentation. Where's the diagnosis header? Where's the laterality? There is no LT or RT in these statements. So, just from that alone, nothing can be coded at all.
 
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