Hello All,
I am coding for home health, if the referral from the provider does not have a definitive dx, are we able to look at the therapy notes and code the dx the therapist has determined? My understanding is that they would be an approved clinician and ok to glean a dx from, even if that dx is not included in the referral documents from the referring provider. I guess what I am asking is what are the appropriate documents that I can obtain a primary and secondary dx from, if ony weakness or gait instability come over on the referral and reason for visit? Thank you in advance!
I am coding for home health, if the referral from the provider does not have a definitive dx, are we able to look at the therapy notes and code the dx the therapist has determined? My understanding is that they would be an approved clinician and ok to glean a dx from, even if that dx is not included in the referral documents from the referring provider. I guess what I am asking is what are the appropriate documents that I can obtain a primary and secondary dx from, if ony weakness or gait instability come over on the referral and reason for visit? Thank you in advance!