Nancy Grisanti
Contributor
Our compliance team has done a random audit of charts in our clinic. They have found that a few charts have a dictated note with a diagnosis of say for example of bronchitis but the physician wrote upper respiratory infection on the superbill. The encounter was coded as bronchitis as it was in the typed dictation. The compliance team feels that the two should be the same and want it brought back to the physician to write the same dx on the superbill. I was under the assumption that the superbill was not considered part of the chart and you should be coding from the dictated note. Please help!