Doctor not wanting to assign a diagnosis code

jnieto625

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Savannah, GA
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One of my coders came to me with the following and asked if the provider should of assigned a code for the acute anxiety and stress reaction:

PLAN:

Hypertension

MEDICATIONS: I will increase the dose of her lisinopril- increase to 30 mg daily for now..
RECOMMENDATIONS given include: perform routine monitoring of blood pressure with home blood pressure cuff, exercise, reduction of dietary salt intake (less than 2000 mg/day), take medication as prescribed, try not to miss doses, and stress reduction.

Prescriptions:
Refill of: Lisinopril 30mg Tablet Take 1 tablet(s) by mouth daily #30 (Thirty) tablet(s) Refills: 5

Orders:
List of current meds with dosages and verification w/ patient or rep documented by the provider (Send-Out)

Tachycardia, NOS Listening to patient, it sounds as though she is having episodes of a true paroxysmal tachycardia, occurring on somewhat frequent basis. I have suggested that when these bouts occur, that she go ahead and take her blood pressure, which will simultaneously show her heart rate, and I would ask her to bring these results and/or contact me with the results so that I can advise on referral to cardiology.


Other Prescriptions: For acute anxiety and stress, secondary to family issues etc., will go ahead and prescribe a short course of lorazepam which she has used in the past successfully. We did review potential adverse effects of this medication Lorazepam 0.5mg Tablet 1 tab PO BID PRN acute anxiety #30 (Thirty) tablet(s) Refills: 0

ASSESSMENT

I10 Hypertension
R00.0 Tachycardia, NOS

I discussed this with the provider and explained that I as a coder would look at this and assign dx code F43.0 (acute stress reaction) and she stated the following:
yes, I know but my point was that i don't want to use the as a diagnosis for this visit. I just want the diagnoses that i
used. I can prescribe a medication without having to give a diagnosis. right?

Help please... Any thoughts on this would be great!
 
Last edited:

CodingKing

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"For acute anxiety and stress, secondary to family issues etc.," is a diagnostic statement so I would say you need to code for it. Absolutely, there would need to be a clinical indication for prescription of controlled substances. What does the physician think they are candy?
 

mitchellde

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Perhaps it is because he does not feel comfortable with rendering a diagnosis for a mental/behavioral condition as he is not ready to give the patient that diagnosis and yet he would like to treat her symptoms as a temporary measure. The is a code for worries R45.2 and others in the same category for other symptoms involving emotional state,that he may actually feel are more appropriate to use for this patient. Many providers do not know that this is available as a choice. If so he may need to word his diagnostic statement to more easily convey that he is treating symptoms of an emotional state and not a mental dx.
 
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