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Wiki diagnosis from chart

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solocoder

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OK, I know that I can not code a dx from a patient's chart, or their previous visit, but can I use that code if the doctor has pulled if from the chart? For example: if DM is not mentioned anywhere in the history, but the doctor lists it in his assessment, can it be coded?
 
solocoder said:
OK, I know that I can not code a dx from a patient's chart, or their previous visit, but can I use that code if the doctor has pulled if from the chart? For example: if DM is not mentioned anywhere in the history, but the doctor lists it in his assessment, can it be coded?
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Was it addressed at all during the visit - meds, counseling, ordering or reviewing blood sugar labs, etc? If so, then yes, it can be coded.
 
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