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Wiki Procedure Report Required?

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KLRuhe

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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
 
I wouldn't be comfortable coding based on that statement, because it doesn't specify "I performed the procedure" so how are you to know the doctor billing for the biopsy is actually the one performing it? I'd also want to see documentation of the method of the biopsy, what kind of anesthetic/how much was used, and whether or not there were any complications...
 
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