Posted on 14. Aug, 2009 by in Toolkit
Unless you want to grapple with denials, the procedure notes that support your physicians’ laceration repair claims should contain these 8 elements. How do the physicians in your practice measure up?
• decontamination (including foreign material removed)
• tissue management
• exploration of wound and contiguous structures
• anesthesia technique
• repair of underlying structures.
Example: A good procedure note for a simple scalp repair might read: “After cleansing with betadine, repaired single-layer scalp wound, 8.4 cm, with 14 4-0 prolene sutures under local anesthesia. No foreign material removed; no repair of underlying structures or tissue management required. Wound and surrounding structures checked, no further trauma found.”
With this procedure note, you should have no trouble getting paid for 12004 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 7.6 cm to 12.5 cm).
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