Wiki Missing diagnosis!

[joanne71178]

Is it not unethical and/or against rules and regulations to code a diagnosis if it is missing from the OP note? I have an office I am coding surgeries for who have left a diagnosis off an OP note and refuse to give anaddemdum. They want to verbally give me the diagnosis.

Please help.

 

[mitchellde]

no it must be in the operative note. Verbal will not be admissible if the record is ever called into court or audit.

 

[joanne71178]

Thank you! This is what I thought.