tci Outpatient Facility Coding Alert - 2019 Issue 4

You Be the Coder: Don’t Leave Reimbursement on the Table With Incomplete Op Reports

Question: My physician performed a 38500, but did not document the closure. I inquired and he is opting not to include it in the operative report. Can I still bill out for the 38500 service? Utah Subscriber Answer: You should inform the physician that it’s inappropriate practice to leave an operative report incomplete. In fact, you can even go as far as explaining to the physician you cannot properly code the procedure without documentation of the closure. While the closure might seem like a trivial portion of the procedure, you’ve got to take into account each of...

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