Wiki 99211 and Documentation

[RAMONA!]

I apologize if this is answered elsewhere, I have not seen it specifically:

Does the Nurse have requirements to document a Dx Code?

Is the Nurse permitted to see a patient and document in the Chart Body, "No diagnosis" and expect that the Coder will give it a 99211?

I am very confused about this; thanks to anyone with information for me.

 

[mitchellde]

The "nurse" can see a patient only if that patient has already been evaluated by the physician in a previous visit and diagnosed at that time. The provider will at that visit write a plan of care that includes that the patient will follow up with nursing staff for the Same plan and same diagnosis. We always had our nurses document that the patient was here in follow for.________, per physician order of xx/xx/xxxx. If there is no previous visit for the nurse to refer to then it cannot be a nurse encounter. To document no diagnosis is not a billable encounter.