marycopus2019
New
I'm really sorry if this has been posted before but I couldn't find anything when I searched the forum (probably because I couldn't figure out how to phrase it correctly.)
Which part(s) of the documentation can coders pull dx codes from? Say, the provider only listed BMI or Obesity on the claim. We have to go back to the encounter notes to see what the provider wrote and pull a good diagnosis. I'm a new coder, but I was taught we could use anything the provider documented (HPI, ROS, Assessment, Plan) but there's another lady where I work who stated we cannot code from history. Not just the medical/surgical history but also the history of present illness.
Can someone please shed some light on this and if you have it, list a source or two where I can check this out myself? I've Googled this so many times and I searched AHIMA, AAPC but did not find what I was looking for. As I stated before, the fact that I didn't find anything is most likely due to not being able to search the correct combination of words or phrases.
Please help (and THANK YOU)!
Which part(s) of the documentation can coders pull dx codes from? Say, the provider only listed BMI or Obesity on the claim. We have to go back to the encounter notes to see what the provider wrote and pull a good diagnosis. I'm a new coder, but I was taught we could use anything the provider documented (HPI, ROS, Assessment, Plan) but there's another lady where I work who stated we cannot code from history. Not just the medical/surgical history but also the history of present illness.
Can someone please shed some light on this and if you have it, list a source or two where I can check this out myself? I've Googled this so many times and I searched AHIMA, AAPC but did not find what I was looking for. As I stated before, the fact that I didn't find anything is most likely due to not being able to search the correct combination of words or phrases.
Please help (and THANK YOU)!