Wiki Documentation for diagnosis

[dkgrabner@comcast.net]

Im not sure if this is the right thread to post this and I hope this makes sense. Is it acceptable to include a physicians signature on a report as documentation of a diagnosis?

Example: SNF resident has a chest xray and the radiologist states in the impressions this resident has COPD (this would be a new diagnosis for this resident), would it be accepted documentation for coding purposes if all the physician did was sign the report acknowledging that the physician had seen the report or would I need a specific statement from the physician in their own words acknowledging and agreeing with the diagnosis?

Thank you for the clarification!

 

[thomas7331]

Per ICD guidelines, code assignment must be based on a physician's statement in the documentation. A diagnosis on a radiologist report would be sufficient if you were billing the radiologist's services. But if you are billing for the services of a different physician who is seeing the patient, you'll need to code from that physician's assessment of the patient's condition from their own words. In my mind, it would be OK to use COPD if that physician documented that the reviewed and agreed with the radiologist's assessment, but not if they just signed the report.