Medicare Surgical Documentation- Surgery Reason vs Type скачать в хорошем качестве

Medicare Surgical Documentation- Surgery Reason vs Type

Q: For Medicare patient, shouldn’t the reason for surgery be documented, not the type of surgery? A: This does not pertain just to Medicare it’s for any payer. Basically, on the surgical report, the very top, the reason for the surgery translates into the preoperative diagnosis – why is the person having surgery. The header of the surgical report (top of the report) should include the pre and post-operative diagnosis codes as well as the surgical procedure performed. You would use the header information to begin searching for appropriate CPT procedure codes as well as your diagnosis (ICD-10-CM) codes. Really, it should include the diagnosis as well as the procedures. After you get that information, what you would do is review the operative report. You first begin with - I look up the procedure and diagnosis codes from the manual based on the header, but then I go right in to the operative report. Then, what I do is I extract all the information out of it, I scan quickly because there may be other procedures that are in that operative report that can be coded. Sometimes they’re bundled into the main surgery but that’s not always the case. So, the header is a consolidation of the surgery performed, not a step-by-step description of what was done. Then after you’ve chosen your codes, you review the guidelines in both CPT and ICD-10 and then use any appropriate modifiers based on documentation: it’s the left, the right, bilateral, and then you want to see if the surgical procedure is staged, like modifier-58, or return to the OR for a complication (78). But basically you really want to have the diagnosis as well as the procedure at the top, along with the patient’s name, date of birth, medical record number and so forth. If you want more extensive information, I’ve given you a link to the CMS.gov website and you can check there and it will have that broken down even more. But any doctor that writes just the diagnosis or the type of surgery, that’s up to you as a coder to educate them and to have it right. It’s hard, you really should have it all together properly. Coach Alicia: Yeah. I think we just did CDI education. That falls right into that, didn’t it?