klightner
New
Hello there! I am hoping to resolve an ongoing question between myself and our hospital coder. If a provider doesn't provider a diagnosis or provides a non-specific diagnosis on an operative note, she uses the diagnosis from the H&P as the surgery diagnosis. As for me on the professional side, I am under the impression that I cannot do this and that the operative note has to stand on it's own. The previous professional coder used the H&P diagnoses as well in these situations but I don't feel that this is the right thing to do. I feel like I should be querying the provider to get the correct diagnosis on the procedure note.
Any information on this and/or a professional source I can reference would be wonderful!
Any information on this and/or a professional source I can reference would be wonderful!