Being "old School" I suggested an addendum to the provider to update his note prior to billing. I was told that according to the AMA you can take the diagnosis from the H&P. That just doesn’t ring true. I might be able to see it for an ASC charge as the facility is getting the H&P as part of chart paperwork but even that is a stretch for me.
I started coding before EMRs, and live by the rules of, not documented not done and stand alone documents, but to make sure I am looking for credible references to
prove that a operative note must have a diagnosis listed. I would love to see anything that the AMA has on this topic, but I have not been able to get into the website.
Can anyone help me?
I have JCAHO Standard IM.6.30 so far.
Thank You