We are having an issue with a provider and I need to find a guideline or policy to back up the coding staff and I can't see to find one. I am hoping that maybe someone can lead me in the right direction.
I know I have read before that each note must stand alone. Meaning....we can't take information from a path report in order to choose the correct surgical code, because the provider didn't document in the chart note either the size of a lesion, that a biopsy was indeed taken...etc. Do you know where I can find information that states something similar to this???
Thanks
April Potter, CPC
I know I have read before that each note must stand alone. Meaning....we can't take information from a path report in order to choose the correct surgical code, because the provider didn't document in the chart note either the size of a lesion, that a biopsy was indeed taken...etc. Do you know where I can find information that states something similar to this???
Thanks
April Potter, CPC