Wiki Coding/Billing for Diagnoses

[MPhillips77]

My provider wants us to use co-morbid conditions when proving medical necessity for urine drug testing (we work in Pain Management). However, these co-morbid conditions are not always noted on the note for that visit. I am hesitant to use codes that the doctor hasn't documented in the note, even though these conditions do not change from visit to visit (examples - depression, anxiety, insomnia, etc). He thinks we can use them without them being documented for that day of service. Which one of us it right? I just don't want us to be in trouble if our charts are audited and they are not noted in the chart. Thank you!

 

[mitchellde]

The only diagnosis that can appear on a claim are documented as being manag d controlled or treated at that encounter.

 

[MPhillips77]

That is what I thought. He seems to think we can use them, even if we are not managing that condition. Thank you for your help.

Melannie