diagnoses coding from a doctors billing slip


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My Billing supervisor wants me to use handwritten diagnoses off a billing slip. The slip is not in the official medical record. It is used mainly for the patient's demographics and insurance info. The doctor will write systolic CHF. It is not in the actual documentation. Does anyone know where I can find a guideline that states what documents can be used when coding for diagnoses codes? Thank you for any help


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There is no guideline that says you cannot use a billing slip to communicate coding information between the physician and the billing staff. But in the end, codes submitted on a claim must be supported by the patient's medical record. If you do not trust that the physician is putting the correct information on the billing slip, I would suggest sampling some records to validate this. If you find that the information is reliable, then there is no problem in doing this, but if you find that the physician is omitting important information that should be reported on the claims, then you may wish to discuss this with your supervisor and suggest that a coder work directly from the medical record instead.