Proper Documents

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.

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