Wiki EHR No Definitive DX

[nscoder]

For one of the EHR systems I code for the provider picks their dx (and the code is attached). How would you assign the ICD-9 codes if the provider chose a code for pnumonia & bronchitis, and then as a side note wrote "not clear if its bronchitis or pneumonia". ICD-9 guidlines state to code signs and symptoms if the provider does not make a definitive diagnosis. Would you replace the chosen DX with signs and symptoms?

 

[m.j.kummer]

For one of the EHR systems I code for the provider picks their dx (and the code is attached). How would you assign the ICD-9 codes if the provider chose a code for pnumonia & bronchitis, and then as a side note wrote "not clear if its bronchitis or pneumonia". ICD-9 guidlines state to code signs and symptoms if the provider does not make a definitive diagnosis. Would you replace the chosen DX with signs and symptoms?

Absolutely!