Wiki Code Z91.19

No it cannot be listed as first dx. How could a patient be non-compliant with other medical treatment and regimen but not have a condition being treated?
 
Z91.19

The patient is being dismissed from the practice and the provider saw them (ROS and Exam performed)and gave them 30 days of medication.

The patient had just left a Rehab Facility AMA so he had no medications.

According to the provider she did not counsel the patient and does not want to add the chronic conditions to the note as she has no medical necessity documentation.

What would you suggest?

Thank you
 
You need a consequence. So if the patient did not follow thru with treatment, what was the result? Otherwise there is no reason to report the noncompliance. If there is nothing else documented then I would say it cannot be billed.
 
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