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Wiki Anemia coding

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kumeena

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Goodmorning everyone. TGIF


Primary care doctor writes his assessment plan anemia along with other diagnosis and refer the patient to hematology. Is it OK to add anemia in ICD 9 coding.He didn't mention on HPI or anyother place in the chart.

Thank you
 
How does he know patient is anemic?

How does he know patient is anemic? Are there labs noted?

Unless someone is using an EHR and dragging old material over, I usually take Dx from the assessment/plan area (might be called impression).

Would help to see the actual note.

F Tessa Bartels, CPC, CEMC
 
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