if pt has DM and is on meds and we have no Documents stating this dx can we still code? i was always taught we code off proper documents and we do not code off a med list. is this correct or did rules change?
Nope, you can't ASSUME patient has DM, as some DM meds are taken for other medical issues. The clinician (or you if you are a RN) can put a call in to MD to confirm Dx of DM and write a note in patient's medical record reflecting that. Then, at that point, if you have confirmation from MD, I would say it is okay to code it.
ok that was going to be my next question . if a SN calls and confirms DX over the phone ... is that good enough ? We still dont need any documents?
the SN will have to document a telephone order: the MD he/she spoke with, when the conversation was had, and that the dx was verified, etc.