Specimen in the report header


True Blue
Midvale, UT
Best answers
Is it enough to say Specimen: skin lesion in the header of the op report and no mention of the biopsy in the body of the report? It just states the redundant levator aponeurosis was trimmed of with Westcott scissors and bipolar cautery was used to obtain hemostais.
Wrong Forum and Need Op Note

For an accurate response to surgical coding questions, please post the scrubbed operative / procedure note.

Also, you will get a more qualified response if you post in the specialty forum that will attract the attention of those coders with the most experience in your issue.

For this issue I'd post the procedure note in the dermatology forum.

Hope that helps.

F Tessa Bartels, CPC, CEMC