Wiki Updating Dx - Source

[Heatherc7]

Hello,

I was trained that the provider needed to update the Dx. I received an update from the office manager to update the Dx for the procedure. I believe it should be the provider whom advises, unless I can confirm on the Op note (FYI - I have to wait for an Op note to be loaded, this can take 1-2 weeks.) I'd love to know your thoughts and experiences on this. Does anyone know if there any legal ramification by the receiving the Dx from someone other than the provider?

Thank you in advance!

 

[catherinetinkey@entmedicalservices.org]

If you don't have an OP note or pathology report the only one giving you a diagnosis should be the physician. How would the office manager know what the diagnosis is. If you put in a diagnosis, then you get the op note and they don't match, what do you do? Amend the op note or corrected claim? Everyone would like to post right away but there are times when you need to wait for the note, especially if there is pathology involved.

 

[Heatherc7]

Agreed. I should clarify the office manager states the provider told them. However, I don't think that is enough. I believe I am required to either have the physican update me or an addedum in the Op note with the updated/correct Dx. I also, agree about there are times you need to wait and see.