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Wiki Diagnosis codes written on Operative reports

vjimenez

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I have a physician who dictates their Operative reports. In the body of the report the physician does not dictate the diagnosis to its severity and/or specificity, just the preoperative diagnosis is documented. The physician does however hand write the post operative diagnosis code to its specificity on the Operative report. Is this acceptable for both auditing and billing purposes? We have asked the provider several times to please dictate but, we are receiving push back from the provider stating that she writes the diagnosis code and that is sufficient enough. Please advise!
 
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