Neoplasm Documentation

01sutton

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Clearwater, FL (81334)
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Hi!

I'm currently doing coding for Hospice. If the physician narrative on the Hospice Initial Certification only states "lung cancer" C34.90 and the patient was just released from the hospital and the hospital physician documents (not radiology reports) as lower lobe left lung C34.32 can that be used?

Also, if our physician does not document information as to smoking/tobacco can that social history information be taken for hospital records?

The person that trained me, said to pull this information from the outside records, I don't feel this is correct.

Thanks,
Wanda
 
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