Wiki E/M Diagnosis

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hajektl

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We were having a debate on if you can put a diagnosis on a claim that is not on the progress note for that day, but you can find it documented in the patients chart. If not where can I find the supporting documentation to back this up and if so the same thing.

Thank you!
 
Each visit date documentation needs to stand on its own. I believe you will find information regarding this in the federal register. I remember an entire section devoted to this topic.
 
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