Wiki ICD 10Coding from Therapy Notes

[tlindo1]

I'm struggling with how to code therapy visit notes for each visit. EX: The patient has initial diagnoses of PTSD, ADHD, Alcohol Use, Opioid Use, and Insomnia. All are coded per documentation. The following month the patient comes in for therapy visit, the clinical documentation only talks about their PTSD. The Therapist adds diagnoses for billing for all of the diagnoses. Shouldn't the only ICD 10 code for PTSD be billed since there is no conversation regarding the other diagnoses? I thought the documentation in the note must support the diagnoses coded. The therapist is just pulling all the diagnoses forward, but I don't know if this okay to do. Please Help

 

[TThivierge]

Tlindo
If provider has it in current for the day documentation of the problem add it on claim. If not discussed or documented NOT counted on claim. That is one of medical coding abstraction rules. This protects you as a medical coder. I hope helped you
Lady T