I've recently started doing some chart reviews. I've noticed many instances where the diagnosis is numerical format only. The charts are paper charts and the documentation is handwritten. I have seen this more from psych providers. In the event of an audit (say CMS) would this be considered appropriate documentation?
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Wiki ICD-9 documentation
- Thread starter LUDS
- Start date
btadlock1
Guest
When you say "numerical form", do you mean they're just listing the ICD-9 code? How do they know they're picking the right one?
Brandi Tadlock, CPC, CPMA
Brandi Tadlock, CPC, CPMA