When coding or auditing the E & M, can you get a diagnosis from the dictated History when the dicatation has the diagnosis listed under the Assessment?
For example, the router or encounter form has a diagnosis marked, but the dicatation does not have that diagnosis listed in the Assessment, but it is mentioned in the History. The diagnosis in the History may be needed to obtain the level of the E & M that was indicated on the router or encounter form.
Also, does anyone know of a good book for auditing and coding E & M that would answer a question like this one?
Candice Brazeale, CPC
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