Where I work we are currently using a program that allows the attending to select an ICD-9 code with attached text. This appears in the final note; however this is the only place the diagnosis is recorded. Can this be used as the diagnosis for the claim or should the attending still document the patient's diagnosis somewhere in the body of their note? I have looked high and low on any rules that apply to this, but all I can find is an article in the February 2010 Coding Edge (pg 29) that makes me think that this cannot be used.
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