KLRuhe
Networker
I am doing an audit on procedure documentation. I would like some opinions on whether a tongue biopsy (for example) needs to have a procedure report. I believe it does, but there is a description in the E/M documentation of the location of the lesion, along with a comment such as, "this was biopsied in the office today with a small amount of local." Is this enough documentation to support code 41100?
Again, I'd like some other opinions.... Am I being too picky?
Thanks,
Kay, CPC
Again, I'd like some other opinions.... Am I being too picky?
Thanks,
Kay, CPC