Wiki Different Diagnocis

[jreisert]

If the diagnocis is different from the report than what is written on the encounter form which one should i code. Thanks.

 

[kymberlyz]

diff dx

where are you getting the info from for the dx? if its diff from the report or encounter form- the dr should sign off on the one he believes pt has- and thats the one you report- if its not documented in blacka nd white and not signed off by dr, you cant code it-hope this helps- if you need further clarification, i would go back to dr and ask for him/her to clarify and update and sign off on document.