Wiki help on dx

[alices]

Good morning How would you code final dx reported rectal bleeding w/o evidience? this one dr. likes to put w/o evidience a quite a few charts so how does everyone handle these situations? he also gives pain meds so I am thinking I need someother dx because of the pain meds in this case he gave the pt fentynal/ Cam I code the rectal bleeding 5693 and
78900 since he came complaining of both?..thank you any and all help is appreciated..alice

 

[Shrina]

I think you need to ask the doctor what he wants for the dianosis. Ultimately, it is the doctor's decision. Ask him/her to clarify. Ask him/her "although the symptom is without evidence, do you still want to code it?" Ask him to add the diagnosis of abdominal pain. You cannot code it without documentation, even if the doc prescribed pain meds.

 

[alices]

re-dx

Thank you..