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Diagnosis Help

  1. #1
    Question Diagnosis Help
    Medical Coding Books
    I have a physician who is writing his diagnoses as "same yesterday". I spoke to him about this and his answer is "you should know what that means". Well, DUH -- what if Medicare request the day of service for 6/10/08 and not 6/9/08, what would he do?

  2. Default
    Try showing this to your provider:

    To ensure that medical record documentation is accurate, the following principles should be followed:

    The medical record should be complete and legible.

    The documentation of each patient encounter should include:
    o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results.
    o Assessment, clinical impression, or diagnosis.
    o Medical plan of care.
    o Date and legible identity of the observer.

    I found this at

    As I often see here: kick him in the bucks.

  3. #3
    Tell your boss that the golden rule for coding is "If it isn't documented, it didn't happen". We are taught that from day one when coding anything. I know how hard it is when dealing with people like that. Hang in there and just keep running him over with information proving your fact!!

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