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Wiki PT Orders - We use Epic

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PLAIDMAN

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We use Epic. I am finding unspecific physical therapy orders being entered....they ARE linked to the encounter e/m

my question is am I allowed to use the chartnote to give a more specific dx to the PT data entry specialist ? I was under the impression that I MUST code to the ORDER ?

example: physical therapy order states: "medial meniscus tear" - but- the chart note states it is a current complex tear.....

AND ...what if the PT order is NOT linked to the encounter e/m ?

appreciate any clarification - my PT people strongly do not enjoy me.
 
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