jennbrad
Contributor
OK so I need some help. I work for a non profit clinic that offers dental, medical, and behavioral health services. I do the coding and billing for the psychiatrist we have, I am constantly sending queries back to him regarding his secondary diagnosis because he documents them in the EHR but does not code for them and his documentation isn't always clear enough for me to do it. We were having a phone conversation last week and he instructed me to disregard his secondary diagnosis' from now on as to avoid any confusion. This doesn't sound any where near being normal procedure to me I was always under the impression if its documented then code it. Please if any one has resources for me or can tell me what I am supposed to do here I'd appreciate it as I am new to the coding world. Thank you in advance.