Wiki Diagnosis Coding for Refills


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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.
if you look in the coding guidelines the V68.x code which you would use for prescription refills is valid only as a first listed dx code. If the condition the meds were being given is not managed or treated you would not code the condition so the only option is to use the V58.83 to show med management which can be listed secondary, followed by the appropriate V58.6x code for the drug which must be listed secondary.
Coding repeat prescriptions

I hope this is helpful. I found this on the AAFP website and I think it states it very clearly.

What is the proper diagnosis code for patients who come in just for prescriptions?

V68.1 is for “Issue of repeat prescriptions.” This does not include a repeat prescription for contraceptives. For that you should choose the appropriate code from the series V25.41-V25.49. You should also code the diagnosis for the condition for which the prescription is issued.

Rachael Price, RN, CPC-HA
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