What is the diagnosis coding guidelines for a coder vs a provider?
I.E.
Provider documents a diagnosis in CC, HPI, ROS but not in Physical Exam
in this providers Diagnosis codes, they have the diagnosis listed but there were no documentations in the Physical Exam.
IF a provider didn't provider diagnosis codes and a coder had to code the document, how will they be able to code the encounter if the diagnosis was mentioned in CC, HPI, ROS only.
What is the guideline to coding a document when it comes to a coder vs. a provider?
I hope this makes sense. thanks.
I.E.
Provider documents a diagnosis in CC, HPI, ROS but not in Physical Exam
in this providers Diagnosis codes, they have the diagnosis listed but there were no documentations in the Physical Exam.
IF a provider didn't provider diagnosis codes and a coder had to code the document, how will they be able to code the encounter if the diagnosis was mentioned in CC, HPI, ROS only.
What is the guideline to coding a document when it comes to a coder vs. a provider?
I hope this makes sense. thanks.