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Wiki Coding Problem

mpete0719

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I just started to work for an Inpatient Psychiatric facility. I was recently told that I will be coding from a Comorbidity Checklist form that the Psychiatrist on staff has created, not a discharge summary. The doctor will have 30 days to complete a discharge summary however, the administrator doesn't want to wait until then to code and bill the chart due to the doctor taking up to 2 weeks to dictate the summary. On this checklist the nursing staff is putting ALL "history of" diagnosis that were from the old medical records the patient came in with. It is my understanding from my education that I do not code anything that isn't well documented in the chart itself. Most of the "history of" diagnosis are NOT documented in the chart at all because they are not relevant to the patient's visit. Any advice on this would be greatly appreciated.
 
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