When reviewing chart notes to provide dx codes to the lab, I came across a note where physician "A" reported a rule out dx in his chart note.
Physician "B" saw the pt in f/u 6 weeks later, as physician A is no longer with our clinic, and documents "Review of the records indicates (pt name) has been diagnosed with (a dx), (a dx), (a dx) and _____ (the dx that the other doc had as a "rule out".
There is no other documentation anywhere that the patient meets criteria for that particular dx; only other mention of this dx is "Family history of"...
In my mind, this is an erroneous diagnosis that needs to be retracted from the pts record.
I would be interested in thoughts/opinions from fellow coders, especially those more experienced than I.
Thanks for the help!
Physician "B" saw the pt in f/u 6 weeks later, as physician A is no longer with our clinic, and documents "Review of the records indicates (pt name) has been diagnosed with (a dx), (a dx), (a dx) and _____ (the dx that the other doc had as a "rule out".
There is no other documentation anywhere that the patient meets criteria for that particular dx; only other mention of this dx is "Family history of"...
In my mind, this is an erroneous diagnosis that needs to be retracted from the pts record.
I would be interested in thoughts/opinions from fellow coders, especially those more experienced than I.
Thanks for the help!