Our office is having a discussion regarding whether or not to add a diagnosis code for refills during an encounter. Often times our providers will write a refill on a RX which the patient originally received from a specialist. There are no notations within the record other than the notation under Orders for that encounter date. I would like to know where I may find documentation to either support the addition of the diagnosis for that medication/refill or documentation which supports not adding a diagnosis. Much mahalo for your response.