Wiki changing documentation based on path report

[smartcoder]

I work for a dermatology practice. Provider removed lesion thinking it as "skin tag" the path report came back as "neurofibroma". Should we go back and chnage provider assesment of skin tag to the neoplasm of uncertain behavior and bill it as shave removal/biopsy or keep the medical recods as it is.

Please help !

 

[FTessaBartels]

Addendum

I would suggest that the surgeon dictate an addendum to his original procedure note indicating that pathology report confirmed that the specimen was neurofibroma.

Hope that helps.

F Tessa Bartels, CPC, CEMC