Wiki Hospice DX Documentation

[cadillacmtn]

Can anyone tell me what documentation would support a dx of cancer in an elderly hospice pt who refuses a tissue biopsy to confirm? Is it standard practice from auditing perspective for the hospice physician to assign a cancer DX as primary if it is obvious from xrays that there is a growing/spreading malignant neoplasm, but no pathology is done, and primary phy only assigned hx of mass?

 

[mitchellde]

The hospice physician documents malignancy? If so then that is what we code. We code diagnosis rendered by physicians. He obviously has enough clinical and diagnostic evidence to feel confident of his dx.