Wiki huge debate---any input appreciated

[micki127]

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

 

[nsteinhauser]

I've always gone by the rule 'not dictated, not done.' In past audits, I've only been allowed to use the dictated report and the path report (if it's a procedure/surgery that produced a specimen) to defend coding decisions. Anyone else?

 

[ABonnell CPC]

If he wants to put in on the encounter form for you to use, thats great, but I cannot imagine why the dx would not be dictated?? That doesnt make too much sense??

 

[dlashua]

I only use what is documented in the note, if the provider has referenced sources outside of the note (lab results, x-rays, pt intake, etc) and has signed and dated those forms as well then I do allow that as part of my decision.

 

[mitchellde]

a coder may code from the medical record only provider rendered diagnosis. Since the encounter form is not an official medical record item then the coder cannot use that as a source of coding information. If the provider references a lab but not the result, the coder may not use the lab generated result form since that has no physician interpretation, However the radiology reports and the path reports have physician interpretation and signatures and may be used as a source of diagnosis. However this is only for the physician and outpatient coders, the inpatient facility coder may not use radiology and path reports only the physician documentation.