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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!