I have a question pertaining to Outpatient Surgery done in a facility setting. Patient has Rotator Cuff surgery repair, but has a chronic condition of overactive bladder that they take medications for, PRIOR to coming to the facility for surgery. They are discharged same day and never need to be administered medications while onsite. Provider never references overactive bladder in their documentation, however the fact patient is on Detrol is in their medication list. Our CQA is stating…

Coding Overactive Bladder as Chronic Condition with Rotator Cuff repair