Deborah h Posted Tue 17th of February, 2015 09:52:12 AM
Does the physician have to indicate the babies' weight in the op note or can it be in the chart? If he indicates the weight, does he have to note the technical difficulty he encounter during the procedure? What documentation is required,and please give a reference to your answer.
SuperCoder Answered Wed 18th of February, 2015 02:48:26 AM
Yes, the physician have to indicate the babies' weight in op note. Please see below supercoder article for more information.
Deborah h Posted Wed 18th of February, 2015 08:12:12 AM
I don't have access to this article; please type out the answer.
SuperCoder Answered Wed 18th of February, 2015 08:30:43 AM
Modifier 63 tells payers that a procedure involves significantly increased complexity and work because the patient is a neonate or infant. Because the patient is significantly small in size, the work can be intense, making it difficult to control the patient’s body temperature and obtain IV access.
Most often, you’ll need to use this modifier for procedures performed during or immediately following delivery. The provider should document in the medical records technical difficulty he faced. Thanks !!
Deborah h Posted Wed 18th of February, 2015 09:18:26 AM
Sorry, but the question is does the physician have to document in their op note the babies weight or can it be listed in the chart? What documentation is required in the physician's operative note before a 63 modifier can be billed?
SuperCoder Answered Wed 18th of February, 2015 10:35:14 AM
Yes, physician can have it documented in either op note or chart or both. And the physician should document the complexity involved in the procedure because the patient is a neonate or infant. For example, "it was difficult to control the patient’s body temperature and obtain IV access because of low body weight of infant". Thanks !