I just got my first billing/coding job in a small one physician office. The problem is that the doctor hardly documents anything. Most of the time the doctor doesn't so much as put a note in the system saying that she saw the patient or even check off on the encounter form what she did or what the diagnosis is. Its a specialty office so we see a lot of the same things but the office manager wants me to just pick codes based off of what it says the patient's appointment was about when they were scheduled and the results from labs. I've also been told that asking the doctor to document more or asking too many questions about a case will only get you yelled at. Have any of you had to deal with this? Am I allowed to code visits without any sort of documentation or word from the doctor? Is that considered insurance fraud? If you were in my position what would you do?