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difference between documentation and path report

  1. #1
    Default difference between documentation and path report
    Medical Coding Books
    My dr documented that he did a shave excision and it measure >2.0, bu the path report shows .9 x .8. dx is a squamous cell in situ.

    do i defer to the path report for coding or to the dr's documentation?

  2. Default
    Go with the provider's measurements. The specimen will shrink and the path report will have a smaller size.


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