Wiki Dx Coding for refills

[BUTCHER129]

Please help solve a difference of opinion between coders. When a patient is seen for an acute illness and during the visit he/she asks for refill of Maintenace medication. If refilled, will the provider also code that DX? (ex: DM). Any input or guidance appreciated.
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[TThivierge]

Hi Butcher
If listed in the documentation you can add last dx Z76.0 med refill. If the provider is just reviewing lab results with patient or monitor medications we use dx Z51.81 or Z71.2 dx lastly on claim. However it must be listed in his documentation for the day treated. Sometimes provider do not know these dx codes.
I hope this data helps you
Lady T

 

[nickelclaw]

I would code the Z76.0, DM code and the drug code