Wiki Obtaining Codes

[janeswitzer]

We are a hospital based reference lab that sometimes needs to call a physician office to clarify or obtain additional diagnosis information. Are there are regulations regarding the acceptance of verbal diagnoses from the office ? Is documenting the diagnosis, name of person who provided it, date,time and individual taking the information adequate since it is already in the medical record of the physician office ?

 

[mitchellde]

no you must have the provider document an addendum to the record. You may not add a diagnosis given verbal. A nurse may add a verbal order for treatments and tests which the provider must sign but the diagnosis must be rendered by the physician and documented by the physician.