SuperCoder Posted Thu 19th of February, 2015 07:42:55 AM
Can the diagnosis on the emergency department orders be used if the diagnosis is not in the dictation? For example ED orders under diagnosis it states Sepsis, however in the dictation, it does not mention Sepsis, it states pneumonia. Are the ED orders used more for R/O diagnosis?
SuperCoder Answered Fri 20th of February, 2015 09:39:55 AM
The diagnosis mentioned in dictation should be same as orders. If dictation does not include that diagnoses, you may not use order diagnoses and it may attract denial. Thanks !!