Wiki Documentation question

[lisner1204]

I have a colonoscopy report that states in the description of the procedure that polyps were removed from the rectum by cold biopsy. This is not mentioned in the impression. Should I have the physician make an addendum to the report?

Thank you.

 

[BenCrocker]

If I remember my learning correctly if it's in the description of the procedure then it's in the record and is therefore useable as is. Impression is basically what the dr is going to be doing in a general overview, I don't think it has to be all exhaustive and inclusive.

 

[kevbshields]

This would be an unnecessary query. Since the provider has supplied a description that includes the mechanism of removal, then there would be no need for further information. This is one of the reasons that coders are taught and trained to read the entirety of a procedure or operative report, to ensure they are capturing all services and diagnoses pertinent to that episode of care. This means that you have enough documentation to successfully code the case and it requires no action from the part of the provider.