Radcoder86
Networker
If a provider diagnosed a patient with acute sinusitis and leaves it unspecified, but in the note states maxillary tenderness, I am not allowed to assume that the diagnosis is really acute maxillary sinusitis, correct? I have a lot of pressure on me to code off of symptoms the doctors put in their notes since they won't specify when they list their diagnoses. I've always been taught I'm not allowed to do this.