Kristen Bensel
Networker
I am hoping that someone can help me with an issue I am having. I know that I have found guidance on this type of situation before, but apparently didn't save it for future reference. So any help you can give is greatly appreciated!
Q: Can I add a diagnosis code based on findings in the exam without it being hard documented in the assessment? (I know signs and symptoms can be in the absence of a definitive, but I wasn't sure with this instance)
My provider saw a patient for post-coital bleeding.
On exam he noted :
On bimanual exam, the uterus is multiparous size and firm
anteriorly raising the question of a small intra-mural fibroid?
There is also a firm mass felt in the anterior cervix with a
question of a nabothian cyst versus small cervical fibroid
raised. No adnexal masses or tenderness.
His assessment is Post-Coital bleeding;
And he is ordering an ultrasound and CBC to rule out another condition.
So back to my question: Can I pick the cervical mass up without querying him since it is documented in the exam or do I have to query him and ask why he didn't add it?
Q: Can I add a diagnosis code based on findings in the exam without it being hard documented in the assessment? (I know signs and symptoms can be in the absence of a definitive, but I wasn't sure with this instance)
My provider saw a patient for post-coital bleeding.
On exam he noted :
On bimanual exam, the uterus is multiparous size and firm
anteriorly raising the question of a small intra-mural fibroid?
There is also a firm mass felt in the anterior cervix with a
question of a nabothian cyst versus small cervical fibroid
raised. No adnexal masses or tenderness.
His assessment is Post-Coital bleeding;
And he is ordering an ultrasound and CBC to rule out another condition.
So back to my question: Can I pick the cervical mass up without querying him since it is documented in the exam or do I have to query him and ask why he didn't add it?