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We are having an issue with a provider and I need to find a guideline or policy to back up the coding staff and I can't see to find one. I am hoping that maybe someone can lead me in the right direction.

I know I have read before that each note must stand alone. Meaning....we can't take information from a path report in order to choose the correct surgical code, because the provider didn't document in the chart note either the size of a lesion, that a biopsy was indeed taken...etc. Do you know where I can find information that states something similar to this???

Thanks

April Potter, CPC
 
April this is medical documentation 101. You can refer to Faye Brown coding guidelines and the coding clinics. This is a non-compliance issue due to the fact that coders should never code from pathology and labarotory reports.

Good Luck
 
I don't have access to Faye Brown's books. Do you have any other sourcese that would be beneficial? I know I am right...I just need the ammo to back me up.
 
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