Florida1
Contributor
Is it appropriate to add additional DX codes as I am reviewing a patients' note for coding purposes? Ie: our practice uses an EHR system, Dr. sees pt and thinks they have a MMT, so he codes it as the tear (not supposed to, I know!) and says that he is sending them for an MRI to rule out. I review the note, I see that the patient presents with knee pain, I want to use the knee pain DX in lieu of the tear that is not confirmed, but the DX of knee pain is not noted under the A&P.....can I add that to the billing based on the patient presenting with it, or do I have to have the Dr. addend his note to include that DX under the A&P?