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Old 05-02-2011, 03:16 PM
mamacase1 mamacase1 is offline
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Question Icd9

Can someone tell me what they would use for lt lower leg inversion?
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Old 05-02-2011, 03:22 PM
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m.j.kummer m.j.kummer is offline
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Quote:
Originally Posted by mamacase1 View Post
Can someone tell me what they would use for lt lower leg inversion?
Can you give a little more information? What type of provider, what service? I like a challenge. Thanks.
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Old 05-04-2011, 08:21 AM
mamacase1 mamacase1 is offline
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family Practice and no other info in dication. thanks for your help.
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Old 05-04-2011, 11:15 AM
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No other info? I would say that means that nothing is addressed making the DX irrelevant to patient management. Omit code or take documentation back to the provider for elaboration. Please remember that you should not be coding diagnoses that are not managed/treated/addressed during a patient encounter as it shows no bearing to patient's care.

For example, if a patient comes in with an earache. Presents with high fever, as well, and is found to have an inner ear infection. The patient was given prescription for ear drops. The doctor documents all this but, in the assessment, decides to bring forward all the patient's DXs without addressing them in any way.

1. Inner ear infection. Patient given prescription of _______ to be dropped into ear canal every 2 to 3 hours for pain and ________ to be taken for the full course as instructed.
2. Constipation.
3. Urinary incontinence.
4. CAD.
5. PVD.

Why should dx #2-5 be coded? There is no indication that these held any bearing to the doctor's MDM for this patient's encounter.

If the doctors are constantly documenting a laundry list of diagnoses without addressing them, it needs to be brought to their attention that a diagnosis cannot be coded without it being addressed in some form.

Hope this helps.
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