If a Dr. writes the description (example: pupal necrosis secondary to decay)of a diagnosis code in the patients chart note but does not provide a the code can a certified coder assign the diagnosis code on the claim form?

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  • If a Dr. writes the description (example: pupal necrosis secondary to decay)of a diagnosis code in the patients chart note but does not provide a the code can a certified coder assign the diagnosis code on the claim form?

If a Dr. writes the description (example: pupal necrosis secondary to decay)of a diagnosis code in the patients chart note but does not provide a the code can a certified coder assign the diagnosis code on the claim form?

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Asked on July 12, 2016
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Yes, as a coder you are responsible for code selection and assignment based on provider documentation.

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Answered on January 1, 1970
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