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Wiki What all can you take from for coding

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bjmon83

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I code for physicians in our out reach clinics. Usually I just code from the route slip and dictation. But if I am lacking information that I need or need to clarify something what all documantation can I take from? If the current documentation doesn't refer to another date, can I look at anything else? How far can I look back?

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You can only obtain information from the current encounter you may not look back, if there is a reference by location and date ( such as in the office note from feb 1 2012), then you may go to that note for relevant history only. If a radiology test was performed on the same day as this encounter or a path report is available for a specimen obtained from the patient on this encounter you may use those but nothing else may be accessed for coding purposes.
 
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