coderforlife
Guest
where can i get a link that states a document has to have the physicians diagnosis listed?
coderforlife
coderforlife
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diagnosis - where can i get a link
- Thread starter coderforlife
- Start date
mitchellde
True Blue
I am not sure what you are needing, only the provider can provide the diagnosis, they must document either the signs and symptoms or a definitive diagnosis in order for it to be coded. They do not have to "list" the diagnosis, it just needs to be within the note, they also do not have to provide the diagnosis code. With out the provider documenting either symptoms or dx we cannot code it.
Check with your local medicare carrier, here in Texas there is a document on Trailblazerhealth that outlines the" general principles of medical record documentation for E&M services". Also the 98 & 97 E&M leveling tool has some information.
Hope this helps.
Hope this helps.
Check with your local medicare carrier, here in Texas there is a document on Trailblazerhealth that outlines the" general principles of medical record documentation for E&M services". Also the 95 & 97 E&M leveling tool has some information.
Hope this helps.
Hope this helps.