Wiki Missing Diagnosis Code


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I would like to know how other coders are handling this problem.

I have a few physicians who dictate follow-up visits but without a diagnosis code. There is no sign/symptoms listed - nothing. (Capturing physicians’ inpatient stays) For some ongoing education is not working.

Any suggestions?

Sample Note

Patient seen on rounds today. Today currently has had no evidence of bleeding last night. Yesterday patient stated he desires to be discharged home today. Today the patient is concerned about transportation to chemotherapary & radiation therapy, how medicines will be obtained once home. States he has limited services. Examination is unchanged. Will consult case management for discussion of placement issues & will obtain an MRI of the brain per recommendations of Oncology.
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Are the adminstrators aware of the issue? When I have a provider that will not adhere to guidelines even after several training sessions, I involve the people over that provider. Also, I wouldn't bill it. When it starts to affect the money that gets their attention.

Good luck,

Laura, CPC