I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider. Sounded easy - first page of the Official Coding Guidelines, right? Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough. Any other ideas?
E/M Documentation guidelines sort of say it (Under MDM):
"The number of possible diagnoses and/or the number of management options that must
be considered is based on the number and types of problems addressed during the
encounter,
the complexity of establishing a diagnosis and the management decisions
that are made by the physician.
Generally, decision making with respect to a diagnosed problem is easier than that for
an identified but undiagnosed problem. The number and type of diagnostic tests
employed may be an indicator of the number of possible diagnoses. Problems which
are improving or resolving are less complex than those which are worsening or failing to
change as expected. The need to seek advice from others is another indicator of
complexity of diagnostic or management problems.
DG: For each encounter, an assessment, clinical impression, or diagnosis should
be documented. It may be explicitly stated or implied in documented decisions
regarding management plans and/or further evaluation.
For a presenting problem with an established diagnosis the record should
reflect whether the problem is: a) improved, well controlled, resolving or
resolved; or, b) inadequately controlled, worsening, or failing to change as
expected.
For a presenting problem without an established diagnosis, the assessment
or clinical impression may be stated in the form of a differential diagnoses or
as "possible,” "probable,” or "rule out” (R/O) diagnoses."
The 'general principles' say that the diagnosis should be clearly indicated, along with the legible identity of the observer, but it doesn't say that it
MUST be a physician. I also think that it probably falls somewhere under 'scope of practice' criteria, but I'm not sure...
![Confused :confused: :confused:](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)