Hello,
There is a debate going on about what is proper coding.... Is it proper coding to get all the info from the office Visit Note or can you supplement the Office Visit note with the encounter form, physical history form and a form that has all procedures typed on it and the provider is checking off the boxes of what the patient had done ie, x-rays, injections and the like.
So in a nut shell is it adequate documentation that if a provider does not dictate in an Office Visit note what the diagnosis is but he writes it on the encounter form then that is accurate enough to code off the encounter form what the dx is?
Any advice will be much appreciated
There is a debate going on about what is proper coding.... Is it proper coding to get all the info from the office Visit Note or can you supplement the Office Visit note with the encounter form, physical history form and a form that has all procedures typed on it and the provider is checking off the boxes of what the patient had done ie, x-rays, injections and the like.
So in a nut shell is it adequate documentation that if a provider does not dictate in an Office Visit note what the diagnosis is but he writes it on the encounter form then that is accurate enough to code off the encounter form what the dx is?
Any advice will be much appreciated