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Biopsy Documentation

  1. Question Biopsy Documentation
    Medical Coding Books
    If a biopsy is not documented in the colonoscopy report, but there is a pathology report on file for the biopsy, shouldn't the provider be documenting this?
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    www.ambanet.net/AMBA.htm
    AMBACode Coding Software
    http://www.ambacode.net
    2015 AMBA National Medical Billing Conference
    http://www.ambanet.net/2015.htm

  2. Default
    yes, the report should clearly state what was done and method. For billing, he can go back and append the OP report to include the biopsy that was done

  3. #3
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    Columbia, MO
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    Default
    I would query the provider for sure. Did he fail to documet that a biopsy was performed? Or was it intentional?? Is the path report for the correct patient. There are many questions to be answered. But you are correct in that if he performed a biopsy he must document that he did.

    Debra A. Mitchell, MSPH, CPC-H

  4. Default Biopsy Documentation
    The problem is, the OM wants to bill 35380 for colonoscopy with a biopsy. I'm not comfortable with that since it isn't documented.
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    www.ambanet.net/AMBA.htm
    AMBACode Coding Software
    http://www.ambacode.net
    2015 AMBA National Medical Billing Conference
    http://www.ambanet.net/2015.htm

  5. #5
    Default
    Hey Cyndee,

    As mentioned by another person in the posts, physician should be appropriately queried as to the accuracy of the documentation regarding the biopsy.

    Should his response to the query indeed include the biopsy service, then the record can be updated (by the physician). This would be considered a "late entry" or "addendum" to the record. There doesn't seem to be any particular time frame set in stone for this type of entry in the record. In general, my research has found the same statement repeatedly.... "addendums should be documented as soon as possible and, while there is no official time limit, the entry becomes less credible and reliable with the passage of time" (a legal aspect).

    Physician would also need to identify the new entry as an “ addendum” or "late entry" and reference the original entry AND, use the current date and time on the addendum entry.

    Hope that helps!
    Susan M. Garrett, CPC, COC
    Past President El Paso Texas Chapter AAPC
    Past Member AAPCCA Board of Directors
    cell 915-204-8333

  6. Default
    Susan and all:

    Thank you so much for your help!

    Cyndee
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    www.ambanet.net/AMBA.htm
    AMBACode Coding Software
    http://www.ambacode.net
    2015 AMBA National Medical Billing Conference
    http://www.ambanet.net/2015.htm

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