Coding, Classification & Reimbursement

DOCUMENTATION ON CT-GUIDED BIOPSIES

  • 1.  DOCUMENTATION ON CT-GUIDED BIOPSIES

    Posted 06-04-2018 12:56
    Happy Monday!
    ​We have a radiologist who has started doing CT-Guided Thyroid and Liver biopsies.  As far as documentation on these, would you consider these  Outpatient Surgery and require an H&P and have him sign an attestation or would you consider these like any other outpatient x-ray and only require the CT report?​  Because I think it would be considered an invasive procedure, I think he should do the H&P and sign an attestation, but I don't want to be overbearing and make him do extra work, if it is not necessary...
    As always, any advice would be greatly appreciated!
    Thanks!

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    Kayla Hill, RHIA
    Director of Health Information/Privacy/CDI
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  • 2.  RE: DOCUMENTATION ON CT-GUIDED BIOPSIES

    Posted 23 days ago
    Edited by Chelsea Bemiss 23 days ago
    We have a similar situation at our facility. What did you end up doing?

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    Chelsea Bemiss
    System Director of Him




  • 3.  RE: DOCUMENTATION ON CT-GUIDED BIOPSIES

    Posted 22 days ago
    Check with your Medical Staff.  It is stated that only procedures that require anesthesia/conscious sedation require H&P or Short Stay Forms in our Medical Staff Rules & Regs.

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    Raquel Joubert
    Coding Supervisor
    East Jefferson General Hospital
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