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documentation

  1. #1
    Location
    casper,wyoming
    Posts
    31
    Default documentation
    Medical Coding Books
    Does any one know where I can find documentation, as to whether you can code from the patient stating what is wrong with them vs Dr. diagnosis? I was always understanding, that you could not code from what a patient says is wrong with them. Am I right?

  2. Default
    you can code from signs and symptoms if there is not a definitive diagnosis.

  3. #3
    Location
    Columbia, MO
    Posts
    12,840
    Default
    AB-01-144 issued September of 2001 was directed to ancillary services such as radiology. To obtain a dx for tests or services it states what constitutes a dx for a test. It can be a script from the physician, an e-mail, a phone call, OR it can come from asking the patient why they are there for that service as long as every effort is made to verify this information with the patients medical record. As far a physician office, this needs to be documented in the patient's chart and not comming from the patient verbally.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Location
    casper,wyoming
    Posts
    31
    Default
    Thank you, We have patients who are actually telling us that they have mets cancer. More than just sign, with no documentation that they do.

  5. #5
    Location
    casper,wyoming
    Posts
    31
    Default
    Quote Originally Posted by mitchellde View Post
    AB-01-144 issued September of 2001 was directed to ancillary services such as radiology. To obtain a dx for tests or services it states what constitutes a dx for a test. It can be a script from the physician, an e-mail, a phone call, OR it can come from asking the patient why they are there for that service as long as every effort is made to verify this information with the patients medical record. As far a physician office, this needs to be documented in the patient's chart and not comming from the patient verbally.
    what issue are you talking about AB-01-144? Is it Coding edge?
    thanks

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