March 28, 2019

Question:
My billing service is waiting for the pathology report and assigning the diagnosis and procedure code for benign or malignant skin lesion removal.  This I completely understand.  However, they are asking me to amend my procedure note accordingly once the pathology report is back.  This is a lot of extra work for me.  Do you think I need to amend my procedure note with the pathology results?

Answer:
Absolutely not.  As long as the pathology report is in the patient’s chart, and available if needed to support billing, it is not necessary to amend the procedure note with the diagnosis.

*This response is based on the best information available as of 3/28/19.