Wiki excision guidelines???

[herrera4]

Just a general question--

When coding an excision and the doctor does NOT dictate the approximate six in op note is it ok to code from path report or should you ask the doc to dictate a new note?

 

[rbeaver]

Coding excision

You can not change a note just to get a claim paid. I have always been told if not documented size code the lowest level. Also, it is according how he did the excision and how far done he went.

Go to Medicares website and do rules about excision and it will give you some good guidelines for this question.

 

[FTessaBartels]

Ask physician to dictate addendum

Doctors, like all other human beings, are not perfect ... they sometimes just forget to dictate the size of the lesion, or get interrupted mid-dictation and it gets left off.

The specimen will SHRINK by the time it arrives at the pathologist, so the physician who is removing the lesion should dictate the size of the lesion PLUS SMALLEST margin required for removal BEFORE the lesion is actually excised.

Ask the physician to dictate an addendum. There is absolutely nothing unethical or fraudulent about this. If s/he refuses to do so, then code to the smallest lesion size.

Hope that helps.

F Tessa Bartels, CPC, CEMC