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Q&A Basic coding lesson from a chart

sue kozlowski

New Member
From the professional fee side, I was taught you can only code from the assessment. If there are diagnoses that are listed in the assessment by the provider that was talked about in the ROS or HPI is fine . But we can add codes to what was talked about in the assessment and physical exam findings if the provider did not list them. Do you agree? I then sometimes hear conflicting information, and it would be great to see a demo on coding an office visit. I am wondering if various employers are different on how they code. One coder mentioned she codes from past medical history, and I was taught you cannot do that. Feedback and demo is appreciated, thanks!
 
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