tci General Surgery Coding Alert - 2002 Issue 11

Documentation Is Crucial for Wound Repair

Because of the many variables involved in choosing wound repair/closure codes, and because payers can easily "check up" on such claims by reviewing the operative notes, surgeons must be especially careful to document carefully and completely. In all cases, says Kathleen Mueller, RN, CPC, CCS-P, a general surgery coding and reimbursement specialist in Lenzburg, Ill., the surgeon should note the depth of each repair in simple terms and include the size of the laceration and anatomic area for each closure. Absent any of this information, documentation cannot support appropriate coding. For example, if the surgeon specifies only "repair of...

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