Question Using information from Physical Exam/ROS?

parcoeliz

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Hi there,
I am a relatively new Inpatient Coder at a hospital, no experience--I like to preface all my questions with this :)
I am wondering: Can I extract information from a physical exam or ROS to help specify a diagnosis? For example--physician documents "right foot ulcer," but there is no specificity in the assessment, and they just carry that dx through the chart. However, in the P.E. it will state "right heel ulcer--subcutaneous exposed." Do I do anything with these specifics? Or just code as it was documented in the assessment? Would you take this information and time to query the physician if it doesn't affect the DRG?
Another example: physician just documents "rash." But, the P.E. states where the rash is.
I am trying to review all my notes, I feel like I learned at my job/hosptial from the lead coder that we can't code from the physical exam/ROS? Thoughts? What would you do with these examples?
 

thomas7331

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My understanding is that you can code from any documentation that is signed by the performing provider. It should not matter from what location within the note you are taking the information, as long as it is documentation that has been reviewed and authenticated by the physician or NPP.
 
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