I have a couple of questions:
*I am new to coding Psychiatric inpatient charts and I was told to code all "history of" diagnosis that the nurses have pulled from a patient's old records and put on the face sheet (s/p hysterectomy, appendectomy, gallbladder removal, cataract removal). The doctor is not documenting the majority of the "history of" diagnoses in his current Physician Orders which is where I code from. It was my understanding that only if the physician writes or dictates a diagnosis is it valid for coding.
*I was also told to code from a form within the Comprehensive Neuropsychiatric Evaluation that the nurses fill out and the doctor signs. However, this is done when the patient is admitted and doesn't have the individual dates of service listed like the Physicians Orders do and it contains every diagnosis that this patient has ever had from their old medical records whether our facility is treating them for it or not.
*The doctor documents an up arrow lipids. He doesn't document hyperlipidemia so I have not been coding this as hyperlipidemia. I have asked the doctor numerous times if it is in fact hyperlipidemia, write it as such. If he does not state hyperlipidemia, I do not code it as hyperlipidemia.
I am the only certified coder in this facility and I have questions as to the coding practices at this facility that no one here can answer. Any clarification would be greatly appreciated.