maine4me
Guru
I am currently performing an audit for one of our family practice physicians. I am finding that there are many issues with the diagnoses in the body of the note versus what is listed in the diagnosis list. Our EMR works in such a way that the diagnosis codes in this list are transmitted to the charge entry staff for billing.
I need clarification on the following: if a diagnosis is in the diagnosis list, but was not addressed in the body of the note, assessment and plan, exam, or HPI, then it should not be billed for on this date of service? Right?
Also, if patient is instructed to take continue taking Vitamin D in the plan for osteoporosis, then it would be inappropriate to code for Vitamin D deficiency since it is not documented in this visit? Right?
I need clarification on the following: if a diagnosis is in the diagnosis list, but was not addressed in the body of the note, assessment and plan, exam, or HPI, then it should not be billed for on this date of service? Right?
Also, if patient is instructed to take continue taking Vitamin D in the plan for osteoporosis, then it would be inappropriate to code for Vitamin D deficiency since it is not documented in this visit? Right?
diagnosis codes, diagnosis coding