Adding Diagnosis

CARRIESA37

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Wausau, WI
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I am wondering how everyone gets diagnosis added in the Outpatient side. Do you as coders enter the diagnosis codes that your providers list out, or is the provider the only person able to enter those diagnosis codes?
Any help/advice is appreciated.
Carrie
 

SharonCollachi

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Clovis, CA
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I am the biller/coder/hr/office manager/personal assistant/chief handholder, etc.

The doctor dictates the name of the condition, and I code it. The doctor isn't even touching a computer at this point, although we are holding out hope that he will. :cool:

If I have a question about the diagnosis, I show him his options.

There is no reason that another person cannot enter a diagnosis code into the medical record.
 

CARRIESA37

Contributor
Messages
12
Location
Wausau, WI
Best answers
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I am the biller/coder/hr/office manager/personal assistant/chief handholder, etc.

The doctor dictates the name of the condition, and I code it. The doctor isn't even touching a computer at this point, although we are holding out hope that he will. :cool:

If I have a question about the diagnosis, I show him his options.

There is no reason that another person cannot enter a diagnosis code into the medical record.
THANK you, I have been a coder for 12 years and had never heard of this, until I started at this new company, and thought it seemed strange, as long as he is the one diagnosing the conditions, I can add the codes, as not everyone knows the "rules" behind coding...
 

SharonCollachi

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Messages
1,870
Location
Clovis, CA
Best answers
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THANK you, I have been a coder for 12 years and had never heard of this, until I started at this new company, and thought it seemed strange, as long as he is the one diagnosing the conditions, I can add the codes, as not everyone knows the "rules" behind coding...
A lot of companies have what I consider to be strange rules that they have implemented themselves.
 
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