If the diagnocis is different from the report and encounter form which one should i code. Thanks
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Wiki Different Diagnocis
- Thread starter jreisert
- Start date
You can code from either. For example if your physician sees a patient for a skin lesion and at the time of the visit doesn't have a definitive diagnosis then you can bill for uncertain behavior. Or you can wait until the path report comes in and bill for the specifics. Both would be correct.
Do you have the specific information on this diagnosis and situation? That would be helpful.
Do you have the specific information on this diagnosis and situation? That would be helpful.
mitchellde
True Blue
Sorry you cannot bill uncertain behavior without a path report. You can use what you know from the documentation without trying to interpret or read anything into it. Or you can code from the path report . A coder can only code from the documentation in the medical record or from a report that has been signed by a physician such as a path report or radiology report. When you say encounter form I am not certain what you are referring to since that term has been used to indicate different things to different people. Always code from the written chart chart note or physician interpreted reports that are a part of the medical record.