clinically infer to come up with diagnosis

audii_girl

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I'm fairly new to coding, however, as we all know the real world documentation is very different from textbook and examples-

How far can coders clinically infer?

say my doctor diagnosed the patient with bipolar disorder depressed and in the notes it says " patient endorses auditory hallucinations but refused to share context"
seeing that, it needs more clarification right? because it will be unspecified-
and under problem list it says bipolar disorder depressed F32.9 < the fact that it says that in the notes, it should be billed as is even though there is little documentation that encounter can be billed with higher level of specificity if there is clinical knowledge and if it's documented accordingly?

F31.31 Bipolar disorder, current episode depressed, mild
F31.32 Bipolar disorder, current episode depressed, moderate

F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features
F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features
 

CodingKing

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You may need to query the provider and ask them to be more specific

the 10/1/16 - 09/30/17 ICD-10-CM guidelines state:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

So you really cant infer much you don't have enough information to be any more specific. F31.9 - Bipolar disorder, unspecified is the best you can do. Also the diagnostic statement needs to be in the providers own words so F32.9 would not be appropriate even if the code is listed in the medical record (especially considering its not a bipolar dx code)
 
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