Kristen Bensel
Networker
This is probably going to sound like a pretty obvious question, but I am really starting to struggle with this after discussions with my coworkers on code assignment.
When I was first starting out as a coder, I was taught that when documentation points for a procedure are missing from a note that it is inappropriate to bill for the service, and also inappropriate to have the provider addend the note with the missing documentation. It should be used as an educational moment for next time. I am now starting to question if this was just the process my lead followed or if this is actually how it should be.
For Example:
MR indicates the following documentation must be in the note to bill for excisional debridement CPT 11042 of a DM Ulcer:
Pre debridement measurements
Location and characteristic of wound
Type of tissue removed (eschar, fibrin, bone, etc.)
Depth of procedure
Amount of bleeding and how it was controlled
instrument used and size of the instrument
patient tolerance and pain control
dressing applied and treatment follow-up
Post debridement measurements
The provider only documents the post debridement measurements, the dressing applied, depth of the ulcer and location along with the instrument used. Can the provider be queried for the missing documentation to be addended to the note or not?
Or a patient comes in for DM nail care-
MR indicates the following documentation must be in the note to support the use of CPT 11721
Characteristics of nails (thick, discolored, painful, yellowed, crumbling)
Number of nails debrided
instrument used
outcome of the debridement (% of thickness resolved, pain resolved, etc.)
Provider documents the characteristics of the nails & number of nails debrided. Is it appropriate to have the provider addend the note with the missing documentation?
This is an ongoing issue I have with some providers in the clinic I work at. These providers know the documentation that needs to be there, but never get it all in the note, and they tend to feel that my guidance is just my personal coder preference. So any thoughts you all might have on this are greatly appreciated.
When I was first starting out as a coder, I was taught that when documentation points for a procedure are missing from a note that it is inappropriate to bill for the service, and also inappropriate to have the provider addend the note with the missing documentation. It should be used as an educational moment for next time. I am now starting to question if this was just the process my lead followed or if this is actually how it should be.
For Example:
MR indicates the following documentation must be in the note to bill for excisional debridement CPT 11042 of a DM Ulcer:
Pre debridement measurements
Location and characteristic of wound
Type of tissue removed (eschar, fibrin, bone, etc.)
Depth of procedure
Amount of bleeding and how it was controlled
instrument used and size of the instrument
patient tolerance and pain control
dressing applied and treatment follow-up
Post debridement measurements
The provider only documents the post debridement measurements, the dressing applied, depth of the ulcer and location along with the instrument used. Can the provider be queried for the missing documentation to be addended to the note or not?
Or a patient comes in for DM nail care-
MR indicates the following documentation must be in the note to support the use of CPT 11721
Characteristics of nails (thick, discolored, painful, yellowed, crumbling)
Number of nails debrided
instrument used
outcome of the debridement (% of thickness resolved, pain resolved, etc.)
Provider documents the characteristics of the nails & number of nails debrided. Is it appropriate to have the provider addend the note with the missing documentation?
This is an ongoing issue I have with some providers in the clinic I work at. These providers know the documentation that needs to be there, but never get it all in the note, and they tend to feel that my guidance is just my personal coder preference. So any thoughts you all might have on this are greatly appreciated.