Coding from Medication List

lwagoner

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Hi -

I'm sure we all know that we are not to assign a diagnosis only based on a medication is used. (Such as assigning diabetes because of Metformin use or assigning pregnancy prevention for birth control pills.) However, I'm having trouble finding an official guideline that states this. Can anyone help guide me to that guideline?

Thanks Bunches -
 

mitchellde

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Since you are no the physician you cannot assign the dx. We as coders use the medication list to tell us other things such as we look to see if they are on insulin if they are diabetic, if they have had prostate cancer but are on Lupron, or breast caner and are on Tamoxifen or Evista. Being on birth control pills does not necessarily indicate pregnancy prevention, the patient might be taking them due to excessive menstruation or for a variety of other issues which can be cover by their carrier. We can learn important information from the medication once we have the diagnosis , but we are not to try and guess the diagnosis only from the medications. This does not have to be spelled out anywhere, it has to do with education and license
 
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