Wiki addendums

[solocoder]

If the doctor has not given enough information in an op note for me to select the appropriate code, is it enough for him to just tell me more information, or is an addendum necessary?
I've always asked them to do an addendum, but we have a new doctor... you know how that can be.

Any thoughts?

 

[mitchellde]

Any information you use for coding must be documented in the note for that encounter or surgery.

 

[solocoder]

Thanks, Debra. I'm going to stand firm on this.
Sometimes I just need to hear a more experienced coder agree with me. ;-)

 

[espressoguy]

Just remember the saying that we live and die by, "If it's not documented, it didn't happen."