When patients are seen in outpatient hospital clinics like Wound Care, Physical Therapy, Diabetic Education, Is there a guideline, CMS rule or other approved reference that allows hospital coders who bill for the physician to capture a diagnosis from a nurse? The physicians are not always on site for the clinic visits and the initial order scans multiple months. We have found that the actual clinician (nurse, physical therapist) that are assessing and treating these patients have great documentation and are much more thorough in supplying dxes that support medical necessity in their progress notes and assessments for the procedures being billed, rather than the initial physician order.
Thank You !
Jill Butt, RHIT, CPC_H