Not sure how to handle this. I review physician notes in the EHR before sending to the Billing Team. My problem is that the physicians diagnosis code does not match his documentation. Example. Breast surgeon sees patient who was diagnosed and treated for breast cancer 5 years previously. The patient returns for yearly visit. Patient has no evidence of cancer and treatment is complete. The physician continues to use the breast cancer diagnosis. His notes are very specific as to post surgical treatment including radiation, chemo, and hormonal therapy, mastectomy, etc. I have been editing the diagnosis to appropriate v-codes. My question is if the chart were to be audited and I changed the code to personal history and the physician is using the breast cx diagnosis in his assessment, would that be a problem because the diagnosis code submitted to insurance does not match the physician's dx code in the EHR.