rmitchell
New
A patient comes into the ER for SOB, fever and cough and a COVID test is ordered. The provider does not state a definitive diagnosis in the note, however, when verifying the ER orders and viewing the ER care timeline in EPIC we can see the test is COVID positive. From a compliance standpoint, is it correct to code from the test results since they show up in the ER orders and on the ER care timeline OR does the provider have to state it in the actual documented note.
Thank you!
Thank you!