Incoming diagnosis

torresreb

Networker
Messages
68
Best answers
0
patient encounter 1/18 .. .at the time of the encounter the patient was being seen for a coagulation issue ... the end plan was that the patient would return for a venipuncture due to the D68.9 ... patient returns 2/19 .. chief complaint: patient here for blood work ...

List of medications - completed (meaning noted)
Medical History - completed (just a list of conditions)
Social History - completed
Surgical History - completed
Procedure - completed (states venipuncture completed today)
Lab work - completed
Preventative Care - completed

that's it nothing else to indicate results etc .. .no plan at the end of the report ... am I still able to use D68.9 because that was the primary reason the patient was back to have the venipuncture? Or should there have been some documentation outlining the condition etc?

thank you so much for any help ... I tried looking at past threads but there were so many opinions and nothing was current so wasn't sure if anything changed ...
 

ehanna

Guru
Messages
149
Best answers
0
patient encounter 1/18 .. .at the time of the encounter the patient was being seen for a coagulation issue ... the end plan was that the patient would return for a venipuncture due to the D68.9 ... patient returns 2/19 .. chief complaint: patient here for blood work ...

List of medications - completed (meaning noted)
Medical History - completed (just a list of conditions)
Social History - completed
Surgical History - completed
Procedure - completed (states venipuncture completed today)
Lab work - completed
Preventative Care - completed

that's it nothing else to indicate results etc .. .no plan at the end of the report ... am I still able to use D68.9 because that was the primary reason the patient was back to have the venipuncture? Or should there have been some documentation outlining the condition etc?

thank you so much for any help ... I tried looking at past threads but there were so many opinions and nothing was current so wasn't sure if anything changed ...


I was taught that each note had to stand on its own. If it were me I would ask for written clarification. Good luck!!
 

torresreb

Networker
Messages
68
Best answers
0
I agree. I have one more question if anyone is willing to provide their opinion ..,

if the chief complaint states: here for follow up for hypertension and DM ..

the Plan at the end states:

"continue with current medication regime "...

this is enough to code both the HTN/DM?
 
Top