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Thread: diagnosis

  1. #1

    Default diagnosis

    AAPC: Back to School
    Hi, okay newish to the field... i am 90% confident i know the answer to this but want to make sure. We are a general health care center and have a pt that has partial care here. He also is dx with esrd per nephrologist and that is scanned into out system (we are on ehr system) however when this pt comes in our docs for some reason never dx this pt w esrd they just do ckd ..so for med record purposed since we have a specialist dx and scanned in we can use that dx even though our docs never used it ritght?

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    You have to use the dx documented by the physician on the day of the encounter.

    Debra A. Mitchell, MSPH, CPC-H

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