Is a pre-op diagnosis required on an operative note? In the past the surgeons I worked with always included the pre-op diagnosis in their notes. I now work for a physician who does not dictate a diagnosis on procedure notes. Before I discuss this with him, I'd like to have documentation for backup. I've searched CMS & can't find any guidelines. I found a guideline on JCAHO, but it doesn't indicate that a pre-op diagnosis is required, just a post-op diagnosis.
Thanks for any thoughts
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join