SDAlward
Guest
We are having some issues in our practice regarding the way our doctor's document things. We have a few doctor's here that think it's ok to dictate "symptoms of" and that we can code for that disease.
Example: Dr's dictation states "patient is having symptoms of angina" or "patient is having symptoms associated with CAD"
They think we are allowed to code that diagnosis.
I told them we cannot pick that up because it is questionable if they actually have it or not. They told me I'm not allowed to interpret their words and to just code what they said. I'm very frustrated because I cannot get them to understand why this is wrong.
Does anyone have any articles or resources they can refer me to so I can show them?
Example: Dr's dictation states "patient is having symptoms of angina" or "patient is having symptoms associated with CAD"
They think we are allowed to code that diagnosis.
I told them we cannot pick that up because it is questionable if they actually have it or not. They told me I'm not allowed to interpret their words and to just code what they said. I'm very frustrated because I cannot get them to understand why this is wrong.
Does anyone have any articles or resources they can refer me to so I can show them?