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Thread: Diagnosis Help

  1. #1
    Join Date
    Apr 2007

    Question Diagnosis Help

    AAPC: Back to School
    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. #2


    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 http://www.cms.hhs.gov/MLNProducts/d...serv_guide.pdf

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

  3. #3
    Join Date
    Apr 2007
    Bangor, Maine


    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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