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Documentation

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dermbillerPA:
Does anyone know if its acceptable to replace a written description with a marked diagram in the chart?  For instance:  Skin biopsy done on left forearm and the body diagram is marked as such. Or melanoma excised from trunk and site is marked on body diagram.  Can this documentation replace a written description? And I'm not referring to replacing an op note. I've checked some carrier policies relating to documentation, but found nothing this specific.  If anyone does know can you back it up with supporting documentation?  Thanks so much.

Michele:
I tried to find documentation on this but wasn't able to.  However, my personal belief is that as long as the information is charted it shouldn't matter whether it is written or a diagram.

PMRNC:
I would say it matters WHO puts it in there..  ;D

Michele:
Good Point!   :D

PMRNC:
As a biller and even coder I stay out of clinical things like this. If it's a part of an appeal I send in the clinical documentation needed and if there is a question I have the provider make decisions where clinical documentation is concerned.

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