Wiki Where can, as a certified coder, can I pull diagnosis from

[iamalicia]

Hi,

Recently I was listening to a webinar and the presenter mentioned that we, as certified coders, have the right to pull diagnosis down to use for coding the encounter.

Does anyone know, besides HPI and AP where I can bring down dx if provider fails to mention a chronic condition?

Thanks,

 

[kimberlywatson]

Can I ask what webinar you are referring to? We can only code based on the provider's documentation.

 

[iamalicia]

Can I ask what webinar you are referring to? We can only code based on the provider's documentation.

I was told that I can pull from the problem list if it affects the treatment plan. This was from a CPMA.