Wiki Documentation required for shave procedures

[opieleabo]

I'm having a problem with a PA who doesn't fully document his procedures. Specifically he diagnosis all shaves as benign neoplasm of unspecified site and will state in the procedure removed lesions but not the location, technique or if the sent them to path. We are on an EMR that requires the provider to pick an ICD-9 with an associated description and then document the treatment under that diagnosis. When questioned he will add shaved to the procedure. Is there anything I can reference to show him I cant bill out the procedure with that lack of documentation?? He hates coders and being questioned, so I have to have something solid to stand on.

ex:
skin exam; pt has multiple skin tags/moles on his body (10) they are either skin colored or brown. largest is 1cm in diameter, smallest is 1/2 cm. nonttp and no redness, no induration. regular borders.

diagnosis; 216.5 benign neoplasm of skin trunk
areas prepped with alcohol and beta iodine, lidocine with epi approximately 2cc administered total. 10 lesions removed and silver nitrate used to stop bleeding. pt tolerated it fine with minimal blood loss.

after my first query he added:
10 lesions removed (5 were 1/2 cm in diameter, 5 were 1 cm in diameter) with flat razor and forceps


Thanks

 

[mitchellde]

You cannot use the code for benign until a path report renders that diagnosis. He never indicates that there is anything suspicious or medically indicated for removal, and never indicates that they are sent to path. This reads like a simple skin tag removal so go with 11200 and dx code 701.9 for skin tag. Be prepared for the payer to deny this as cosmetic. But you cannot code a skin tag as a benign neoplasm without a path report.