Can an extra point be counted in the number of diagnoses/treatment options section if a provider only states to continue the same medication and dosage for a different problem? For example, a patient came in for a check up and needed to have his meds changed for his bipolar disorder since it was worsening. Would an additional point be added for hypertension as a stable established problem if the medication for that was continued at the same dosage?
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Wiki Determining # of dx in MDM
- Thread starter BCJ927
- Start date
Diagnoses in MDM
I would then err on the side of caution. If the physician did not directly address the diagnosis...no exam, no updated history but just causally mentioned to continue the medication, let it go. Best to be safe than to be sorry. For some odd reason, coders seem to wear a big old target on their backs and the insurance companies are armed with the bows and arrows.
Good luck!
Happy New Year
Joyce
I would then err on the side of caution. If the physician did not directly address the diagnosis...no exam, no updated history but just causally mentioned to continue the medication, let it go. Best to be safe than to be sorry. For some odd reason, coders seem to wear a big old target on their backs and the insurance companies are armed with the bows and arrows.
Good luck!
Happy New Year
Joyce
LTibbetts
Guest
Read your ICD-9 Coding Guidelines, Section IV - under outpatient coding guidelines. Always check your guidelines when in doubt!