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jenp2005

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I am looking for a link to the AMA or MGMA or CMS that would state that diagnosis within a note can only be entered by the provider seeing the patient. I have a doctor that wants either the coder or a nurse to add them to the note and then he will approve them. Any thoughts would help?
Thanks,
 
I'd like to know if there is documentation regarding that as well, but I doubt that it is required that a physician enter it. The physician signing the note means that he agrees with everything within the note - including the diagnosis.

Example 1: At a wound care center that one of my physicians works at, the diagnosis is entered by the nurses. When he signs off on the electronic record he is agreeing with the diagnosis.

Example 2: In our office the physicians write the note. One of them enters the diagnosis which I often have to change to the right code or add diagnosis that he did not include, but was documented in the note. I then close the encounter and he counter-signs agreeing with everything within the note (including diagnosis).

Example 3: Another physician in our office never enters the diagnosis - I review his note add the diagnosis code(s) and LOS and close the encounter. He then counter signs agreeing with everything within the note (including diagnosis).
 
Only the provider may document a chart note. The AHA coding clinic states the provider must document the diagnosis in his own words. The codes however can be determined by any qualified professional coder. The numerical code does not belong in the medical record document and can never be used in lieu of the providers render diagnosis. The codes on the claim do not need to match codes that are inserted into a chart note, but must match the providers narrative diagnosis.
 
mitchellde - that's a better answer then I had :)

I assumed the question asked was if the nurse or other person could add the codes in the diagnosis field within the EHR system - not if they could enter it into the physician's note.
 
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