Question Physician coding based on their note only - guidelines

DanaClark

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Could someone please direct me to guidelines stating that in physician billing/coding you can only code based on what is included in the physician's note for that specific date of service? I have a physician questioning why we can't look at other documentation within the patient chart. Thank you for any guidance you can provide.
 

thomas7331

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While the ICD-10 guidelines do not explicitly state that you cannot look at another part of the patient's chart, all of the guidelines direct you to code the conditions that are present or affect treatment at the current encounter, and the coding rules require that this be based solely on physician documentation. Conditions that existed at previous encounters may have resolved or changed status, or a diagnosis may have changed due to additional information received or other factors. A coder may not code from past encounters because the coder cannot make the assumption that a particular condition from another encounter is still valid for the encounter being coded. It would not be appropriate to assign a code without physician documentation that the condition existed and was relevant at the time of the encounter you are coding.
 
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Henson65

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Could someone please direct me to guidelines stating that in physician billing/coding you can only code based on what is included in the physician's note for that specific date of service? I have a physician questioning why we can't look at other documentation within the patient chart. Thank you for any guidance you can provide.
What other documentation are they wanting you to look at and consider? And is this for E/M coding or is this procedural coding? If E/M some documentation can be pulled from other places if the physician has notated he agrees with findings or has reviewed specific information.
 
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