Hi. I am a Nurse and CPC. In my current position at a large multi-hospital healthcare system, I work closely with our HIM dept using mostly my clinical background to deal with medical necessity claim issues, primarily outpatient Medicare. I am wondering if we have a prescription for a doppler study with a dx for an unspecified DVT, which does not meet medical necessity, if the physicians office note supports pain in the leg ( a covered dx for a doppler) can the pain in the leg be coded from the MD note if it is scanned to our EHR system? Or are we required to get an amended RX? Essentially, I have been told an office note cannot be used for coding since the note is specific to the MD office encounter and not the outpatient visit. Or is coding from an office visit note for outpatient service based on facility policies? Thank you!