Health Information Management

Facilities bill technical component for procedures using facility resources

APCs Insider, December 5, 2008

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Q. When a patient comes in for a wound debridement, the physician dictates a note that states the medical necessity of the debridement. The nurse is present, but the physician does not mention it in his note. The nurse has a check box that states vitals and any new signs or symptoms. Does the nurse need to document this information in the chart and use the check box? Does the physician need to document that the nurse assisted with the procedure in order for the facility to receive reimbursement?

A. Because the patient is presenting for a specific procedure (wound debridement) that uses facility space, routine supplies, and possibly staff resources, the facility should bill for the technical component of the procedure. A separate evaluation and management code is not appropriate in this scenario, even if the nurse takes vitals and documents signs and symptoms.

(This question was adapted from Briefings on APCs.)



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