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Wiki Diagnosis coding-If the patient is

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dawnkurelko@yahoo.com

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If the patient is there for arm pain and that is the only thing addressed in the documentation, and in the impression patient is given a refill on anxiety medication is the diagnosis for anxiety added to that dos?
 
you can't code anxiety unless the physician documented that condition. If it is listed under the chronic condition list then you could code it.
 
It is in the problem list. I just wasn't sure if you can add that to the dos if only a prescription was given and anxiety was not mentioned in the HPI or chief Complaint
 
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