MorganDodson34
New
If a diagnosis is in the "chief complaint" example: "Chief Complaints: finger pain and RA"
BUT is not listed elsewhere in the note, can the RA be diagnosed?
Most of my providers will make statements such as "patient is here for fu for rheumatoid arthritis" and continue with note and findings.
One of the providers does not do this, the only mention of what is being discussed is in the "chief complaint". The provider will start a note as "patient is here today for 3rd visit" and continue on with findings ect, but not list an an actual reason. Is this sufficient for billing diagnoses?
Thanks in advanced!
BUT is not listed elsewhere in the note, can the RA be diagnosed?
Most of my providers will make statements such as "patient is here for fu for rheumatoid arthritis" and continue with note and findings.
One of the providers does not do this, the only mention of what is being discussed is in the "chief complaint". The provider will start a note as "patient is here today for 3rd visit" and continue on with findings ect, but not list an an actual reason. Is this sufficient for billing diagnoses?
Thanks in advanced!