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Wiki Documentation for a DX

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LKaf7

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Hello,

Is the following documentation sufficient to use a DX for seizure disorder?

"discussion about seizures and need for f/u with specialist"

Nothing was managed, does that matter?
 
I believe that a discussion with a patient about a problem and need to see a specialist does qualify as 'managing' something, but even so, I would not use this statement as a diagnostic one. The provider should have documented what they have diagnosed or suspect is the problem, and in the absence of that you can still code the patient's symptoms as the reason for the service.
 
I can't comment on whether that it is a diagnostic statement without seeing all the documentation but I can say, seizure NOS (R56.9) is not coded the same as seizure disorder NOS (G40.909). R codes in chapter 18 describe symptoms, signs and abnormal clinical and laboratory findings NEC. Be careful to not code a patient with a "disorder" when the doctor doesn't state it that way. You can only code what's documented.
 
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