Wiki MD not slecting level of visit or diagnosis on EHR

[SandraJStone]

I am coding for a new facility and they have purchased several MDs.
We have some MDs who document time, level of service and diagnosis, within the EHR,but then we have some who do not have time , diagnosis, or level of service, documented in the EHR. It is all left up to the coder to chose. Is this standard practice?

Sandra Stone CPC
sj.stone@hotmail.com

 

[rnrray2005]

The diagnosis should be documented otherwise all you can code is the symptoms that are mentioned.... but the general purpose of a coder is to be able to take all the documentation from an exam and come up with a code but we can only do what is documented. So depending on the doctor and if you are getting the complete description of exam you should be able to code from their notes.