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Click here for more sample CPC practice exam questions and answers with full rationale

Sufficient documentation

Need feedback on the proper documentation of a procedure, I have included a snip of documentation we are seeing for some of our procedures in e.g. ( endometrial biopsy). Any feedback on if this qualifies as sufficient documentation would be greatly appreciated.

Pelvis: Ext nl
Vag nl, not a prominent cystocele, but not fully eval’d
Cx nl, descends well for LAVH, but borderline for straight TVH
utx af 10.5cm. lg amt tiss ???
No bladder assessment done

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