Diagnosis From Patient?

[suemt]

I'm looking for some citing for using the patient questionnaire to develop ICD-9 coding, for example, if the script from the referring physician is either silent or vague on diagnosis, can you develop a diagnosis from information you get from the patient?

 

[mitchellde]

AB-01-144 States you may obtain the information from the patient as long as every effort is made to verify it with the physician record.
"On the rare occasion when the interpreting physician does not have diagnostic information asto the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.
Example: A patient is referred to a radiologist for a gastrograffin enema to rule out appendicitis. However, the referring physician does not provide the reason for the referral and is unavailable at the time of the study. The patient is queried and indicates that he/she saw the physician for abdominal pain, and was referred to rule out appendicitis. The radiologist performs the x-ray,and the results are normal. The radiologist should report the abdominal pain as the primary diagnosis."

 

[suemt]

Thank you! I knew it was there some place.