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To bill an E/M service with a minor office procedure (such as an injection), you must have documentation supporting the need for an additional assessment beyond that for the injection

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As a criterion of the Sloan–Kettering classification, a definition has been proposed whereby carcinoma is classified as poorly differentiated if ≥5 mitotic figures are seen per 2 mm 2 or tumor necrosis is present, regardless of the histological architecture or nuclear findings