We use Epic. I am finding unspecific physical therapy orders being entered....they ARE linked to the encounter e/m
my question is am I allowed to use the chartnote to give a more specific dx to the PT data entry specialist ? I was under the impression that I MUST code to the ORDER ?
example: physical therapy order states: "medial meniscus tear" - but- the chart note states it is a current complex tear.....
AND ...what if the PT order is NOT linked to the encounter e/m ?
appreciate any clarification - my PT people strongly do not enjoy me.
my question is am I allowed to use the chartnote to give a more specific dx to the PT data entry specialist ? I was under the impression that I MUST code to the ORDER ?
example: physical therapy order states: "medial meniscus tear" - but- the chart note states it is a current complex tear.....
AND ...what if the PT order is NOT linked to the encounter e/m ?
appreciate any clarification - my PT people strongly do not enjoy me.