Wiki Validity of order

[Kimberley]

I am questioning whether or not this order is valid since the clinic entered one thing under "Procedure" and then in the Clinical Indications field, they typed in the exact study that they wanted. Would this hold up as an order if we were to be audited?


PROCEDURE: Fluoro facet inj, single level, lumbar only R once

Clinical indication: Patient needs repeat bilateral L4 and L5 facet injection

 

[mitchellde]

The coding of the procedure should be based on the content of the procedure note and not necessarily on what the "title" of the procedure states.

 

[Kimberley]

What I posted was actually what the order says, not the report???