Wiki Diagnosis for visit

[Kisselml]

Just wondering, on a PCP visit, that a dx should NOT be used if the notes state the condition is being treated/followed by a specialist, i.e. cardiologist, oncologist etc...

 

[pscanlan]

It doesn't matter if the patient is referred out to a specialist, so long as they still have the condition you can and should code it. Your PCP has to account for that heart condition when he does his own medical decision making, like prescribing drugs that may interact with heart meds. In fact having that condition may contribute to the complexity of the medical decision making, and thus push a visit from 99212 to 99213, or what have you. Multiple conditions would usually increase complexity even more, depending on the severity of the condition. So yeah, I would tend to include those types of diagnoses.

Hope this helps.