Wiki Coding Question.

[Brose02]

As a medical coder am I allowed to add an additional DX from the medical records received from a Referring Physician to us?

 

[thomas7331]

It depends on what you are coding. If you are coding for a specialist's office, you can only code from the encounter as your provider has documented the patient's conditions and you have to rely on your physician to document that those conditions exist. If your provider documents having reviewed the referring physician's notes and he or she agrees with that physician's findings, then it would be appropriate to code those diagnoses.

On the other hand, if you are coding for tests or procedures that have been ordered by a referring physician, then you can use the diagnoses and the record that the physician has given you, since you are coding services that have been ordered incident to the referring physician's plan of care.