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Wiki Symptom documentation for 19318 reduction mammaplasty

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MYAEKEL

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Sometimes when our dr performs 19318 reduction mammaplasty they only give symptomatic macromastia as the diagnosis on the op report. Since insurance doesn't consider this medically necessary with just 611.1 dx the symptoms need to be coded as well.
Our dr doesn't want to add the symptoms to these op reports & wants us to use the symptoms documented at pt's first visit. I don't really feel comfortable coding dx for the surgery that aren't on the op report but, the symptoms are in the pt's med record. Any thoughts on this?
 
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