Wiki Final Diagnosis

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KoBee

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Having a debate, as a coder if no final diagnosis is documented, it is okay for us to capture signs and symptoms. We have a provider who feels there is no need to document a final diagnosis and want us to assume the diagnosis. If anyone was looking at this chart note, would you just make an assumption of pregnancy diagnosis?


Here is an example of chart note:

currently 23-year-old was seen a week ago which IUD and a positive pregnancy test She wanted the IUD removd -she was told of the risks of an ectopic and was counseled -a repeat HCG shows normal increase -she has no pain or bleeding -vagu/s today shows a normal iup crl 0,5 cm 6wks 2days -at patient request she was referred for a termination to Family Planning Associates medical grp inc in Riverside see TVS photo
 
I would code that as pregnancy. "Vag u/s today shows a normal iup". IUP = intrauterine pregnancy.
I will admit it's not as clear as it could be, but does not rise to "assuming" the diagnosis in my opinion. "Assuming" the diagnosis should not be done, but to me the physician does have the diagnosis information in words (or abbreviations in this case) clear enough to assign an appropriate diagnosis code.
 
I would also say a DX for the presence of the IUD would be appropriate here, probably Z97.5-Presence of (intrauterine) contraceptive device or Z30.43-Encounter for surveillance of intrauterine contraceptive device.

According to the long description of Z30.43-Codes in this category are assigned not only for the initial introduction or implantation of contraceptives, but also for surveillance and ongoing evaluation of the devices, including counseling by medical personnel and the encounters for removal.
 
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