Wiki Diagnosis

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kathy a

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I have an older Retina physician who still does handwritten notes. Sometimes she doesn't always give me diagnosis codes but instead gives me history codes. She may also give me codes that she doesn't address in the note. My question to you is can I give diagnosis codes from diagnostic tests ( her findings ) or any other things she may mention in her drawings or exam. I do not use any diagnosis codes if I do not find that condition or issue in the note. Does a condition have to be under her diagnosis and plan in order to use.
Thank-you
Kathy
 
The assessment and plan should address those problems which were evaluated during the exam. The list of those problems in the A/P should give you the diagnosis codes to include with the billing. If the problem isn't addressed during the exam, then you shouldn't code for it.

Tom Cheezum, OD, CPC, COPC
 
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