surfroxy223@yahoo.com
Guest
Hello. I work for a pain management office, and our providers consistently document the diagnosis code on their note, but they do not outline or support that diagnosis code in their assessment. The closest they get is their signs and symptoms. As a coder, I want to document what is outlined in their assessment (just the signs and symptoms). But one of our providers is insisting the diagnosis code itself is sufficient enough. Can anyone help me support my decision? Am I right in my way of thinking? Especially with ICD-10 coming up, their way of just documenting the signs and symptoms wont support very much. Any input is greatly appreciated!