Wiki Colonoscopy coding - I have a problem

[sandyH5]

I have a problem I hope someone can help with. I code outpatient hospital and I have a doctor that did a colonoscopy and his op report states that it was a straight screening colonoscopy. I have a nursing record and a path report that states he did a biopsy. when he was asked to amend his op report to include the biopsy he refused stating he didnt do one. Even the medical director spoke to him and he refuses. So now I am being told to just go by the op report. I know that is not right. HELP!!

 

[Jamie Dezenzo]

was the the path report and nurse notes verified by the doctor for that patient?

 

[slcomstock]

As a coder, you have to code strickly by Doctor's documentation. No matter what everone else in that chart says.