Wiki Coding History

[lgoram]

Per our physician, he states that on a visit that we can pull diagnoses from medication lists and active problem lists even if he does not assess or document
anything to do with those diagnoses. For example, he states to look at a medication and pull down the diagnosis that goes with it as a current diagnosis
for that patient for that day even though it was not discussed on that visit. I am of the understanding that if something was not discussed or documented
it cannot be coded. Please help.

 

[ehanna]

Per our physician, he states that on a visit that we can pull diagnoses from medication lists and active problem lists even if he does not assess or document
anything to do with those diagnoses. For example, he states to look at a medication and pull down the diagnosis that goes with it as a current diagnosis
for that patient for that day even though it was not discussed on that visit. I am of the understanding that if something was not discussed or documented
it cannot be coded. Please help.

I respectfully disagree with your physician and believe you are correct. We have been taught each note must stand on it's own merit. If he doesn't specify in the impression and plan we would not add additional codes.

I hope this helps

 

[mitchellde]

The guidelines indicate that we code those conditions that are managed controlled or treated or those that may be mentioned in the plan of care as a complicating condition.

 

[lgoram]

Lisa Goram, CPC

Thank you for your responses.