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Dr. writes dx code - is that enough documentation?

  1. Default Dr. writes dx code - is that enough documentation?
    Medical Coding Books
    If a doctor wrote 296.32 code under assessment but in the body of the note he only states "depression" would it be enough supporting documentation to code major depressive disorder. Pt is on medication and all the sights of major depressive disorder are documented. But no where in the note he states that patient has major depressive disorder. The only documentation is the code 296.32.
    Should I code it as 311 or 296.32?

  2. #2
    Columbia, MO
    The provider cannot use a DX code in lieu of his dx rendered in his own words see coding clinic 1st quarter2012

    Debra A. Mitchell, MSPH, CPC-H

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