Wiki coding compliance

[asweet4886@gmail.com]

If a provider marks unspecified for the diagnosis on template. However, they list right or left side in the procedure/office note. Does this note need to be addend by the provider for proper diagnosis or am i able to bill it based on what is in the note?

 

[thomas7331]

It should be billed based on what is on the note. The claims must be supported by the note - if audited, it will not matter what was marked on the template, only whether or not the notes match the claim, so there is no need for an amendment.