Tonyj
True Blue
I've been taught if it isn't documented it didn't happen but I have a disagreement with my fellow coders when submitting supporting documentation.
For example; If a clinician did not include sq. cm excised from several lesions removed in their op note (only the total sq. cm of all the lesions) and the insurance company wants supporting documentation;
A) Can the op note be submitted with the path report supporting the dimensions of the lesions billed?
B) Or, does an addendum need to be included on the OP note to support each lesions' sq. cm supported by the path report?
C) Are there any documentation guidelines I can reference for physicians to abide by?
Personally, I'd suggest educating the physician to always include the dimensions of the lesions removed.
For example; If a clinician did not include sq. cm excised from several lesions removed in their op note (only the total sq. cm of all the lesions) and the insurance company wants supporting documentation;
A) Can the op note be submitted with the path report supporting the dimensions of the lesions billed?
B) Or, does an addendum need to be included on the OP note to support each lesions' sq. cm supported by the path report?
C) Are there any documentation guidelines I can reference for physicians to abide by?
Personally, I'd suggest educating the physician to always include the dimensions of the lesions removed.