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bella2

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Hi,

I know this is probably a silly question, we have a Doctor that is performing cataract surgery, on his op note the only diagnosis he gives is just "Cataract"
but in his H&P he actually specifies the type of cataract "Nuclear Sclerotic"
For reporting purposes I believe the only Dx I can use is the one on the op note the unspecified cataract 366.9. I would love to hear some imput on this one as I queried the Doctor and asked that he specify the type of cataract on his op note, and he just said that it was listed on the H&P.

Thanks in advance for any reponses.
 
Not a silly question...I get confuse with this too...I guess is 'ok' to use the Nuclear Scerotic DX if it is documented on the H&P, but honestly, if it is not documented on the Ope Note and feel more comfortable using the 366.9...I think we need to instruct our doc's to be more specific on the Ope Notes...only my opinion:p
 
Yes you can use the diagnosis from the H and P.!!!! We can use the entire medical record to select our code for what was done and why it was done. However the doc should be more specific in his op notes.
 
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