nc_coder
Expert
The physician performs an excision of lesion. On the procedure note it states "excision of lesion". The site and size of the lesion was recorded in a previous progress note when the lesion was examined but not on the note for the date of the procedure.
This data actually needs to be documented on the procedure note too, right?
Please advise. And include points of reference if you can.
Thank you.
This data actually needs to be documented on the procedure note too, right?
Please advise. And include points of reference if you can.
Thank you.