Never Assume a Diagnosis

Question: If the provider documentation states that a patient is taking a certain medication, may we report the diagnosis that the medication is meant to treat?
Answer: Never infer a diagnosis from medications prescribed, test results, or any other data, no matter how informed or educated your opinion. If the provider doesn’t explicitly document the diagnosis, you cannot report it. There are many reasons for this, a few of which include:

  • Medications may be prescribed “off label” or for a variety of conditions;
  • Tests results may be ambiguous
  • You do not want to mistakenly label a patient with a diagnosis that he or she does not have
  • The diagnosis (whether correctly assumed, or not), may not be relevant to the current service
  • You do not want to submit claims unsupported by documentation.

“Not documented = not done” is often called the Golden Rule of coding, but behind it lies a more fundamental directive: Never assume anything. Instead, if documentation is unclear or incomplete, query the provider for more information.

John Verhovshek
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About Has 576 Posts

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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