Wiki ICD-10 Coding Question

[mizz_emoore@yahoo.com]

My coworkers and I are needing some clarification on if we are allowed to submit a diagnosis on a claim without any literal interpretation throughout the medical record documentation; however at the bottom of the note the provider refilled a medication and pulled the diagnosis header above the refill. For instance COPD is on the claim but no where in the note did the provider document the patient having COPD or anything related to the diagnosis but at the bottom of the note the provider listed a medication with a COPD header. Thank you!

 

[kaybrowning]

My coworkers and I are needing some clarification on if we are allowed to submit a diagnosis on a claim without any literal interpretation throughout the medical record documentation; however at the bottom of the note the provider refilled a medication and pulled the diagnosis header above the refill. For instance COPD is on the claim but no where in the note did the provider document the patient having COPD or anything related to the diagnosis but at the bottom of the note the provider listed a medication with a COPD header. Thank you!

If the Physician did not document it, it doesn't exist. Query the Physician about the diagnosis and proper documentation.

 

[TaThompson05]

I cant find the article about it, but I believe if its a chronic on going issue that the physicians treats on a regular basis it does have to be noted every time, It sounds like the patient came in for another issue which was noted and then while there got a med for on going COPD. I would search the AAPC articles I know I read one about this just cant find it.