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Documenting Shave Biopsies and Kenolog


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Ok first question when my doctors do a shave biopsy they are briefly dictating that they did a shave biopsy and where it was done. Once in a great while they may list the size. This is very frustrating and I'm afraid if we ever get audited we'll be in big trouble. Can you please tell me how your doctors document the shave biopsies. I feel that maybe they should do a mini op report so that all the details are listed.

Also, when a kenalog injection is given should the doctor be dictating how much and what strength of kenalog was given? Because again I get a simple line of where the shot was given and thats it.

Any input would be greatly apprecited because my office manager wants me to have a coding meeting with the doctors. So I am trying to have them do this the easiest way possible and for me to get all the information.

Thanks in advance


True Blue
Best answers
I would highly recommend that they document the sizes as well as the amounts of medication injected, any anesthesia that may be given, etc. I think that the idea of a mini op note would be great. Perhaps have a pre-typed form with all of the different options available for them to at least either write in or circle may be of benefit. Of course make sure that there is a signature/date on this as well.