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Wiki Inpatient diagnosis code help..coding from MD orders

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sphaines

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Is it okay to code an inpatient diagnosis from the doctor's order for a test..i.e. chest xray? My thinking is it needs to be documented someplace else in the medical record. Thanks!
 
sphaines said:
Is it okay to code an inpatient diagnosis from the doctor's order for a test..i.e. chest xray? My thinking is it needs to be documented someplace else in the medical record. Thanks!
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Are you coding inpatient for the facility or the physician?

As an inpatient/facility coder, I am allowed to code from the physicians orders.

Cordelia, CCS, CPC
 
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