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Missing size for lesion excision

  1. #1
    Red face Missing size for lesion excision
    Medical Coding Books
    I am reviewing old services, 2004 - 2005, some do not have the excision size documented, can I use the pathology report sizes where the "gross description of specimens received" are noted?

    Thank you in advance for your help!

  2. #2
    Albany, New York
    That is exactly what I do.
    If it is noted on the OP report, I use measurement indicated on Path report.
    I definitely think that this is an area where surgeons need a refresher on documetation/ dictation.
    Karen Maloney, CPC
    Data Quality Specialist

  3. #3
    Thank you Karen, I really appreciate the info!

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