Wiki coding question please help

[katerina_98]

I need to know what the correct coding guideline is for the following example:

pt comes in ear pain still going on, in exam portion of progress note, physician states effusion/redness of ear, but on his dx: only writes persistant OM? What code is appropriate, and where can I find the guidelines that state how the physician writes his dx is how you have to code?

 

[margaritamoore]

E/M

I am not understanding what your exact question is. You can have Otitis Media with an effusion. You need to take the chart with you to the physician and ask him if this was what he meant. A lot of doctors do not code to their highest level of diagnostic care. Then you can properly attach the correct diagnosis. OM or OM with effusion would be the proper diagnosis.