Wiki Insufficient Documentation

[clbarry8033]

I am having problems finding enough information in one of our wound care doctors' documentation to pull a diagnosis code. Does anyone know if it is okay to use written diagnosis codes that a provider has signed off on, even though the actual notes from the provider don't support them?

Thanks!

 

[mitchellde]

No you cannot do this. The diagnosis must be written/dictated in the providers own words and a code is not an allowable substitute.