Provider Coded Outpatient Encounters
I need some assistance with a question that has been raised regarding Outpatient CDI role. My example is: A provider sees a patient in the outpatient clinic. The clinical documentation is great and he has documented appropriately. However, when he completed the visit's encounter form or superbill, he left off a diagnosis that was documented. It wasn't that he used an unspecified diagnosis, he documented it appropriately, but didn't put it on the encounter form/super bill. The CDIS reviewed the documentation and codes that he selected and noticed that he had not listed one of the diagnoses documented. Should the CDIS send a query to the provider, have a coder review and add the code, or should the CDIS add the code themselves to the superbill?
Any help would be appreciated. Thanks!