If I am to verify the coding of the doctor, does the doctor need to be very specific in the charting of documentation. For example, doctor gives diagnosis of
I50.41 (acute combined systolic (congestive) and diastolic (congestive) heart failure). But in Medical History only CHF is documented. Another example is
I83.813 (varicose veins of bilateral lower extremities with pain) In documentation does Dr. need to say all of the key pieces in documentation, usually all I get are varicose veins of lower extremities. Nothing about pain.
My problem is, I am to verify the codes the Dr. gives. However the codes given are more in depth that what the information is documented in the chart. I don't understand the concept of the doctor giving the codes then the coder verifying them.
Thanks for your help.
I50.41 (acute combined systolic (congestive) and diastolic (congestive) heart failure). But in Medical History only CHF is documented. Another example is
I83.813 (varicose veins of bilateral lower extremities with pain) In documentation does Dr. need to say all of the key pieces in documentation, usually all I get are varicose veins of lower extremities. Nothing about pain.
My problem is, I am to verify the codes the Dr. gives. However the codes given are more in depth that what the information is documented in the chart. I don't understand the concept of the doctor giving the codes then the coder verifying them.
Thanks for your help.