# Advice Needed!



## joanne71178 (Feb 13, 2013)

Is it not unethical and/or against rules and regulations to code a diagnosis if it is missing from the OP note? I have an office I am coding surgeries for who have left a diagnosis off an OP note and refuse to give anaddemdum. They want to verbally give me the diagnosis. 

Please help.


----------



## em2177 (Feb 13, 2013)

If it is not documented it doesnt exist.....


----------



## drjohnson (Feb 13, 2013)

*Lack of Dx*

Federal Register/ Vol. 63, No. 243/Friday, December 18, 1998/ Notices

Among the risk areas the OIG has identified as particularly problematic are;
1. Billing for items or services not actually documented
2. Upbundling
3. Upcoding
4. Inappropriate balance billing
5. Inadequate resolution of overpayments


----------



## joanne71178 (Feb 14, 2013)

What if they want to send the diagnosis through email to attach to the OP note?  Would that be acceptable? 

Thank you!


----------



## mitchellde (Feb 14, 2013)

no I think not, he must append the medical record himself.  Why is the provider not wanting to append an addendum?


----------



## joanne71178 (Feb 14, 2013)

You support my thoughts on this.  My guess why they don't want to ask the Dr. to dictate an addendum is because the surgery date is 11/27/12.  I emailed the Manager on 11/29/12 asking for an addendum w/no response until recently.  This is when they emailed the diagnosis code and I told them that was not sufficient.  
Thank you for your response.


----------



## mitchellde (Feb 14, 2013)

Good for you!  are you an off site billing service?  I am just curious no other reason.


----------



## joanne71178 (Feb 14, 2013)

Yes, I am off site.


----------

