Wiki does diagnosis have to be written out?

[tanyawalls]

I have a physican who wants to use the ICD-9 codes on his notes instead of writing the diagnosis out. Can anyone point to a souce for backing me up that the diagnosis has to be written out?

Tanya

 

[jackson7591]

Here it is

http://www.univhc.com/docs/Doctors-Hospitals/Provider_Progress_Note_Documentation_Memo.pdf

In use of abreviations

I'll look in cms.gov tomorrow. But this is at least a start

 

[mitchellde]

I am not sure about a source for saying you cannot do this but, the diagnosis codes are updated every year. If you only use the codes in your documentation, 6 years from now that code may no longer have the same meaning as when you used it.

 

[jgf-CPC]

Nowhere in the notes does it have the Dx written out? Just the ICD 9 code? Or he gives you the ICD 9 on the charge slip and writes the written Dx in the chart?

 

[wtnnicole14]

If his chart note has a written diagnosis then he can use the icd9 code on the superbill.... But the provider does need to be aware of the yearly changes to icd9 codes. ICD9 codes are to be used based off of documentation. The provider needs to have documenation of the diagnosis written out.