Wiki Coding from "Title of Procedure Performed"

[dpumford]

Hello~ The surgeon does IE: colonoscopy and in his reports he states; "As Stated Above " . He does not mention the technique in the body of report

HE dictates the technique under the Title of Procedure he states IE: polop removed by forceps x1, In trans colon, Hot Bx forcepts x 3 and snare polyectomy x 2 left colon...

What I am questioning is it ok to code from the Procedure Title? He does make the statement "as stated above".

I would like to see the technique in the body of report but its not happening, this old habit are hard to break and would like to know if there is any info out there that explains this.. I have looked with no success.

Thank you so much!

 

[EricaR]

Very interested to see if anyone can produce anything supportive on this subject! Our Drs. also wanted to do this, we did not think it was appropriate and had them start dictating it in the body. That being said we do have a Dr. who will have the body of the report pretty much always the same and then dictates findings and how polyps were removed at the end of report under "findings".