Question Do auditors look at this information?

trarut

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Hello everyone. I've recently started at a new practice and noticed the oncologists I work for don't always include the specific disease location in their history or assessment but the notes include the cancer staging details from when the patient was originally diagnosed. Can you - would you - as an auditor pull the specificity from the staging for coding purposes?

For example:
The history/assessment states "Stage 4, EGFR exon 19 deletion, non-small cell carcinoma of the right lung".
The staging included in the note is:
Non-small cell lung cancer​
Location: right lower lobe, bronchus or lung​
Date of Diagnosis: 3/2018​
TNM staging: T1c, N0, M0, Staging type: pathologic.​
Stage at diagnosis: ia3.​
Line of therapy: 1st line.​

Could you code this information together to assign C34.31 for right lower lobe lung cancer or would you have to assign C34.91 for right unspecified lung cancer?

Thanks in advance!
Tracy
 

Sparkt

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Absolutely. The location of his cancer has not changed since the staging and Like Deona4S noted he signed and finalized this report.
 
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