tlindo1
Networker
I have a question about diagnosing from a physician's order/phone order. Is it acceptable to code a diagnosis from an order if the physician states the diagnosis on the signed order?
In the guidelines, it states:
19. "The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider."
With that, what is considered a physician's diagnostic statement? If they order a medication, add the diagnosis and sign the order, is that enough to add the diagnosis code?
This has been really troubling for me, as I have always thought that to code a diagnosis, it must follow MEAT. However, if they are being evaluated and receiving treatment by the nurses, does it fall under that criterion?
In the guidelines, it states:
19. "The assignment of a diagnosis code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider."
With that, what is considered a physician's diagnostic statement? If they order a medication, add the diagnosis and sign the order, is that enough to add the diagnosis code?
This has been really troubling for me, as I have always thought that to code a diagnosis, it must follow MEAT. However, if they are being evaluated and receiving treatment by the nurses, does it fall under that criterion?