atitus
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The CPC's often go into charts and add addendums in order to document any code corrections they make to what the provider actually coded in the chart. The coders have been documenting the code entered by the provider, the complete description of the code, the code they replaced it with and that codes entire description and they document the reason the code was changed.
For example:
Added diagnosis codes L27.0 (generalized skin eruption due to drugs and medicaments taken internally) and T36.0X5A (adverse effect of penicillins, initial encounter) per note.
Per (provider name), ANP, on 5/7/2019, added diagnosis code J06.9 (acute upper respiratory infection, unspecified)
The coders spend a lot of time spelling it all out and I wonder if that extensive of documentation is really necessary. Could the documentation just say
Added diagnosis codes L27.0 and T36.0X5A per note
Per (provider name), ANP, on 5/7/2019, added diagnosis code J06.9
Do we really have to provide the complete description of the code to be compliant?
Thanks for your input.
For example:
Added diagnosis codes L27.0 (generalized skin eruption due to drugs and medicaments taken internally) and T36.0X5A (adverse effect of penicillins, initial encounter) per note.
Per (provider name), ANP, on 5/7/2019, added diagnosis code J06.9 (acute upper respiratory infection, unspecified)
The coders spend a lot of time spelling it all out and I wonder if that extensive of documentation is really necessary. Could the documentation just say
Added diagnosis codes L27.0 and T36.0X5A per note
Per (provider name), ANP, on 5/7/2019, added diagnosis code J06.9
Do we really have to provide the complete description of the code to be compliant?
Thanks for your input.