tci Part B Insider - 2015 Issue 1

Part B Coding Coach: Differentiate Good vs Bad Documentation With 2 Hysterectomy Op Notes

Save these on-the-go documentation tips to ward against big mistakes. You should never rely on the title of your surgeon’s op note to choose the appropriate CPT® code—otherwise, you could be setting yourself up for a denial. Compare these two hysterectomy operative reports and learn what makes a good and bad note — and what to do about it. Examine Example of Poor Documentation Preoperative diagnosis: Uterovaginal prolapsePostoperative diagnosis: Uterovaginal prolapseOperation: Hysterectomy; anterior and posterior repair Procedure: The patient was placed in a lithotomy position, and the perineum and vagina were prepped in the usual sterile manner...

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