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Need help with documentation

  1. #1
    Lafayette Louisana
    Default Need help with documentation
    Medical Coding Books
    I need help trying to find documentation guidelines specific for lesion sizes that MUST be sized in the OR and not from the pathology report. I have a surgeon that refuses to document the size of breast cysts he removes, he said he doesn't need to. I am trying to make him understand that anything you send to pathology should be sized in the OR. Can ANYONE help me find documentation stating lesions must be sized in OR so I can show this to him in writing. I am so frustrated at this point, even my administrator went to bat for me with no luck.

    Gail Boutin

  2. #2
    In my opinion, it is not necessary for them to document it for us to be able to chose a code for breast procedures. The codes are the same regardless of size, its more about per breast mass excised. It would be great to set up rules all across for excisions procedure/documentation guidelines for your own practice... As an auditor's point of view, it should be fine without it in the op note, what we pay attention to more are margins in breast lesion removals... But make sure you remind him that the coding team is just helping him report his codes in compliance with insurance companies guidelines to prevent any pay back for non-efficient documentation... for skin excisions, codes are chosen by diameter and does need documentation in op note, sizes on path reports are not accurate as the specimen tend to shrink..tell him that...

    Hope that shows a different point of view.

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