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Posted By Lillian on 05-08-2018, 10:56:26 in Ob-Gyn
Could someone please educate me so that I can pass this on to my physician how to "properly" document an SIS in a patient's chart? The sonographer charged out the procedure and the main complaint says the patient is in for an SIS but he has no idea how or where in the chart to document for it. It seems that all of the providers in my group are documenting it differently and I'd like to teach them the proper way across the board. Thank you
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Posted By Melanie Witt on 05-08-2018, 18:48:31
Is there a place in your EHR where a procedure can be documented? If so, it would go there. As they are billing 58340 (in the surgical procedure section) he would need to describe what he did in a fashion that is similar to other procedure notes: why was it indicated, what did he do (the procedure steps), his findings (if any) the patient's condition after the saline/dye was injected. So I would say if there is a place in the record to put an IUD insertion, the SIS injection should go there as well.
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