tci General Surgery Coding Alert - 2014 Issue 4

Documentation: Take 7 Steps to Ensure a Great Medical Record

Give your surgeon the right tools. If it’s not documented, it wasn’t done… or so the saying goes. When it comes to general surgery coding from an op report, you can take that to the bank.  With new CPT® 2014 codes firmly under your belt and ICD-10 implementation bearing down on you, now is a great time to focus on documentation that can help you earn all the pay you deserve and avoid audit problems — or even fraud charges.  ICD-10 and CPT® Require Details Whether assigning a diagnosis or procedure code, you’ll need...

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