Wiki Diagnosis specificity

[DK47]

May a coder use the exam for specificity without having to task the provider? The provider states they documented location in the exam and does not need to re-address the location in the assessment?
The coder would like the location listed under the assessment. Very interested in the response and where I can find guidelines to support the answers?

Provider posted:
Left Breast Lump (N63.20) however the exam states Left breast: Superior lateral peri areolar

 

[Orthocoderpgu]

When I first started E/M coding years ago I would sit down with auditors every six months while they reviewed our records. I'm only saying this so you know my source of information. The auditors taught me that as long as it was in the medical record, it did not matter if it was in a specific area of the document or not. Take it for what its worth and lets see if an auditor can give us any additional information.

 

[csperoni]

I've never sat with an auditor (but would love the opportunity) and have the same conclusion.
It's certainly easier for everyone if the items are under the appropriate headings, but even if they are not, they still count. I would consider it a "best practice" to have it in the correct heading, but it's not required.