tkermode
Networker
- Messages
- 45
- Location
- Red Bluff, CA
Can diagnoses from the ordering provider's chart note be used for the radiology claim if the chart note is attached to the radiology order?
My auditor stated that diagnosis information from the ordering physician's note(s) cannot be used on the radiology claim, and that we can only use what is on the literal order and in the radiologist's interpretation.
Does anyone have a reference to support/dispute this? I feel that in the current digital age, where the orders and notes are all digital and linked together, we should be able to use the ordering provider's note to clarify a diagnosis (i.e., location of pain when the order says "pain" or location of injury when the order says "MVA").
Unfortunately, I am unable to find an official AHA or CMS guideline either way. Any help would be very much appreciated!
My auditor stated that diagnosis information from the ordering physician's note(s) cannot be used on the radiology claim, and that we can only use what is on the literal order and in the radiologist's interpretation.
Does anyone have a reference to support/dispute this? I feel that in the current digital age, where the orders and notes are all digital and linked together, we should be able to use the ordering provider's note to clarify a diagnosis (i.e., location of pain when the order says "pain" or location of injury when the order says "MVA").
Unfortunately, I am unable to find an official AHA or CMS guideline either way. Any help would be very much appreciated!