07-17-2026 More Than Just a Number: Capture Both the Lab Value and Interpretation
Scenario:
- 07-01-2026 Colonoscopy w/ biopsy: Ascending Colon Mod Diff Adenocarcinoma
- 07-15-2026 Right Hemicolectomy
Question: Which entry below represents how a CEA lab value should be recorded in your text?
- CEA 2.5
- 07/05/2026 CEA 2.5
- 07/05/2026 CEA 2.5 (elevated)
Answer & Rationale: 07/05/2026 CEA 2.5 (elevated)
To fully support coding of the CEA Pretreatment Lab Value SSDI and CEA Pretreatment Interpretation SSDI, your text documentation should include:
- Date the lab was performed
- Lab value reported
- Interpretation (elevated, normal, positive, negative, etc.)
Example:
- 07/05/2026 CEA 2.5 (elevated)
This single statement substantiates:
- The lab was performed prior to treatment
- The CEA pretreatment lab value (2.5)
- The CEA pretreatment interpretation (elevated)
| Text Entry | What’s Missing? |
| CEA 2.5 | Date and interpretation |
| 07/05/2026 CEA 2.5 | Interpretation |
| 07/05/2026 CEA 2.5 (elevated) | Nothing! Complete documentation |
| Pretreatment CEA not available/not done | Nothing! Complete documentation |
Remember
Date + Value + Interpretation = Complete Lab Documentation
If any of these components are missing, the text may not fully support the coded SSDI values.
Bottom Line: Don’t just document the number. Document the date, the value, and the interpretation so your text fully supports both the pretreatment lab value and interpretation fields.
