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Wiki Diagnosis Coding

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mbabou

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I have a question I am hoping for some input on: We use electronic medical records. Physicians assign a diagnosis code/codes for every visit electronically. I have a physician that frequently assigns diagnosis codes to established patient office visits that are not stated within the current office note dictation. The physician states symptoms that could be associated with the assigned diagnosis but never states the assigned diagnosis within the dictation. The physician has assigned and stated the diagnosis at a previous visit and continues to use this diagnosis for all follow up visits. Would you require the physician to change the diagnosis code to the symptoms since they are never stating it within their dictation?
 
Educate physicians

Oh yes, the joys and tribulations of EMR.

I would remind my physicians that their dictation MUST match the diagnosis codes they selected on the EMR. (I'm assuming they are doing the EMR selection while the patient is still in the office, but probably not dictating until later in the day.)

EMR is a TOOL, it is not a substitute for good documentation.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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