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Thread: Source/Citation needed

  1. #1

    Default Source/Citation needed

    AAPC: Back to School
    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???


    April Potter, CPC

  2. #2


    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

  3. #3


    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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