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L_Silva CPC

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Does any one know where I can find documentation, as to whether you can code from the patient stating what is wrong with them vs Dr. diagnosis? I was always understanding, that you could not code from what a patient says is wrong with them. Am I right?
 
AB-01-144 issued September of 2001 was directed to ancillary services such as radiology. To obtain a dx for tests or services it states what constitutes a dx for a test. It can be a script from the physician, an e-mail, a phone call, OR it can come from asking the patient why they are there for that service as long as every effort is made to verify this information with the patients medical record. As far a physician office, this needs to be documented in the patient's chart and not comming from the patient verbally.
 
Thank you, We have patients who are actually telling us that they have mets cancer. More than just sign, with no documentation that they do.
 
AB-01-144 issued September of 2001 was directed to ancillary services such as radiology. To obtain a dx for tests or services it states what constitutes a dx for a test. It can be a script from the physician, an e-mail, a phone call, OR it can come from asking the patient why they are there for that service as long as every effort is made to verify this information with the patients medical record. As far a physician office, this needs to be documented in the patient's chart and not comming from the patient verbally.

what issue are you talking about AB-01-144? Is it Coding edge?
thanks
 
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