tci Medicare Compliance & Reimbursement - 2007 Issue 33

SURGERY: A Few Extra Words In Your Documentation Could Add $140

If every excision looks the same, it's time to ask questionsPhysicians at Aurora Health Care were stuck in a documentation rut. When one of them excised a pressure ulcer, they would document every single one the same way. So every time, Aurora was billing just the pressure ulcer, with a primary suture and no complications. Until coder Rhonda Gudell started asking questions. "You're telling me that every single last one of these you're doing exactly the same way?" she asked the doctors. Of course not, the doctors said. Each pressure ulcer excision procedure was different, and sometimes the...

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