tci General Surgery Coding Alert - 2011 Issue 5

Practice Management: Distinguish Facility's Documentation Rules From Surgeon's Report

Concentrate on your physician's thorough note. Myth: When your surgeon performs surgery in a hospital, you should coordinate your coding with the hospital's records. Reality: Although that rule is smart for surgeries performed in ambulatory surgical centers (ASCs), it isn't true for facility-based surgeries. When it comes to coding for your surgeon's work, stick to your physician's documentation as a guide regarding what to report, and don't stress about what the facility documents. Here's the lowdown: The facility is governed by a different set of rules than the office-based surgical coder, says Suzan Berman, CPC, CEMC, CEDC, senior manager...

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