You could use it as a reference, but in my opinion you cannot report the diagnosis code directly from the H&P only. The (outpatient) operative report must contain the diagnosis and that is what must b... [ Read More ]
It's in the CMS State Operations Manual, Appendix A, Survey, Protocol, Regulations and Interpretive Guidelines for Hospitals, which can be found [URL='https://www.cms.gov/Regulations-and-Guidance/Guid... [ Read More ]