Lesion removal

[Debi]

If a patient comes in the clinic to have the lesion removed, the provider has not documented the size of the lesion. The dictation states

"The patient presents for two scalp lesions. Been there for years. No change but in the way and get caught while combing hair and bleed.
Shave excision of each lesion under local anestheitc without difficulty."

That is all that I have to work with. A fellow co worker told me that I could code to the lowest size if the provider will not correct his dictation. Is this correct?

Thanks!

 

[Laureen]

yes that is commonly done but or course work with your physicians to provide better documentation.

 

[Debi]

Thank you for your insight. I love CCO, everyone is so helpful. It is good to have a site that provides feedback.

 

[Laureen]

Thanks Debi - we love those seniments. Spread the word - that's how we power this community - so far no paid advertising!!

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