purplescarf23
Networker
Good morning, I've always been instructed (for over 12 years) that the diagnosis MUST be documented in the MDM portion of a chart note. Even the guidelines cover this in that section and don't address it in other sections of the E/M. However I have a few Vascular providers pushing back that the diagnosis can be taken from anywhere in the note. I don't agree with this. However does anyone have something stating one way or the other? I've googled the web more times than I can count and come up with nothing each time. Any help is greatly appreciated.
Thank you
Kelsey, CPC, CEMC
Thank you
Kelsey, CPC, CEMC