Wiki Coding from the "Procedure Title"

[dpumford]

Hello~ The surgeon does IE: colonoscopy and in his reports he states; "As Stated Above " . He does not mention the technique in the body of report

HE dictates the technique under the Title of Procedure he states IE: polop removed by forceps x1, In trans colon, Hot Bx forcepts x 3 and snare polyectomy x 2 left colon...

What I am questioning is it ok to code from the Procedure Title? He does make the statement "as stated above".

I would like to see the technique in the body of report but its not happening, this old habit are hard to break and would like to know if there is any info out there that explains this.. I have looked with no success.

Thank you so much!

 

[pineapplelvr]

I would say it's bad practice to use the title....we require them to say they made it all the way to the cecum etc....do they do this for an EGD too? we require them to say they made it to the duodenum.