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Notes & dx's

  1. #1
    Default Notes & dx's
    Medical Coding Books
    Ok, so here's my question. I get a superbill w/notes from the visit, the dr will write the dx on the superbill, but sometimes I see that a dx he wrote down, I don't see any notes regarding it. Do I tell the dr I need more notes?
    example: pt came in, cc was chest pain. the superbill has a dx of chest pain, depression, hypertension.
    I see no notes that the depression or hypertension were talked about. Aren't you supposed to have some kind of note that lead the dr to that dx?

    I'm going to sneak in another ? Can a cc really be as simple as "monthly follow up visit"? It seems very vague to me.

    Thnx

  2. #2
    Location
    Ellenville, New York
    Posts
    1,176
    Default Yes, question the doctor...
    You can't assign a code just off a superbill - it must be documented in the note. You are correct in asking about those two conditions not documented but circled on the superbill. For your other question on a cc for a follow up visit, as long as the condition that is being followed is documented, that is fine, such as "f/u htn."

  3. #3
    Angry
    The way I'm understanding it is, if there is no note re back pain then you cant use that dx, correct? If the pt had a previous dx of depression, but I dont see any notes in this current visit, then you dont use the dx of depression, correct?
    What about a cc of several things, ex: ingrown toenail, dizziness, then the dr codes a dx of diabetes, shouldnt you code the toenail & the dizziness too?
    Am I making too much of this? I'm still new to the field, but I want to do it right.

  4. #4
    Location
    Ellenville, New York
    Posts
    1,176
    Default
    Quote Originally Posted by bkwrmz7 View Post
    The way I'm understanding it is, if there is no note re back pain then you cant use that dx, correct? If the pt had a previous dx of depression, but I dont see any notes in this current visit, then you dont use the dx of depression, correct?
    What about a cc of several things, ex: ingrown toenail, dizziness, then the dr codes a dx of diabetes, shouldnt you code the toenail & the dizziness too?
    Am I making too much of this? I'm still new to the field, but I want to do it right.
    Yes - no back pain if not in the note. For the previous dx of depression, if there is nothing to indicate the current status, then no, I would not code "depression." You can use a history of that condition, especially if the doctor believes that it is important in the current course of treatment.

    The cc of several things - again, what did the doctor document? Maybe he mentions something about the toenail even though he doesn't actually treat it, such as listing it as a diagnosis later in the note. Same with dizziness - maybe he mentions that pt is AAO x 3 - that would show the dizziness has subsided if it was previously mentioned.

    Keep this in mind from our discussion - I am basing these suggestions on the questions you pose, not from actual documentation. That is what is crucial to your code selection.

  5. #5
    Default
    Thank you, I thought I was thinking of this the right way, but wanted to have someone else's opinion. I need to get my dr to document WAY better!!

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