Documentation Tips

Documentation Tips: Procedures

Documentation Tips: Procedures

LACERATION REPAIRS:

The summed length of all angles of the REPAIR should be documented rather than the simple diameter of the unrepaired wound. Exact location of each separate repaired area must be clear and the layers or suture materials should be documented. Significant debridement and revision of wound edges should be documented as it can affect the complexity of the repair. You might mention, “x.x cm by repair” to clarify that your measurement differs with the nurse’s note when yours is based on the length of the repair.

DEBRIDEMENT:

the CPT code for debridement of skin, dermis and/or epidermis only has been deleted form CPT; the replacement code CPT 97597 is based on the size of the area debrided. The dimensions of debridement (“ 2.5 cm by 10.0 cm”, or “25 sq. cm”) must be measured as there are add-on codes for anything more than 20 sq cm. and the depth must also be clear. Debridement of anything deeper than skin, dermis and/or epidermis (subcutaneous, fascia and/or muscle) has separate higher valued CPT codes based on size and depth – subq/dermis, muscle fascia and, bone; there are add-on codes for anything more than the 1st 20 sq cm.

NAIL REMOVAL:

there is a difference in reimbursement between removal of part of the nail or the complete nail as well as removal of the nail wedge with debridement of the nail fold. If a partial nail avulsion is done with debridement of the nail fold document it as such for better reimbursement.

INCISION AND DRAINAGE:

document whether loculations were broken up or if packing is placed as these increase the complexity resulting in a higher level than a simple abscess drainage. For abscesses, note the incision instrument and the precise location as CPT codes vary accordingly.

CPR:

cardiopulmonary resuscitation must be documented; ACLS protocol does NOT support CPR coding. There are numerous ACLS protocols that do not require CPR so when CPR is done make sure it is documented as such. When it begins in the field be certain to clarify if it continued in the ED under your supervision.

NASAL EPISTAXIS

: note how the control was achieved; limited cautery, simple gauze packing, extensive cautery or use of a nasal tampon, anterior vs. posterior, bilateral, as CPT codes vary accordingly.

FOREIGN BODY REMOVAL

: Note the precise anatomic location of each foreign body and whether each involved an incision with a needle or scalpel. Note depth, any radiographic guidance or localization techniques and whether extensive dissection was needed to locate or facilitate the removal. Code choices and reimbursement vary significantly based on these parameters.

FOREIGN BODY REMOVAL FROM THE EYE

: Note the structural location (conjunctiva/sclera/cornea) within the eye of the foreign body and whether it was superficial or embedded. If a slit lamp was used this must be documented.

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