Medication Management and Assessment


San Diego
Best answers
If a provider sees a patient for wheezing and breathing problems and before the end of the visit ends up filling the patients prescriptions for chronic problems like hypertension, gout, cholesterol and osteoporosis but only codes for the wheezing in the assessment and the plan only describes the treatment breathing problem.

He did write that he refilled the prescriptions just not under the assessment part of the note, should the extra 4 diagnoses be coded?

Should the coder add the extra 4 diagnosis to the claim, have the provider write an addendum and add the codes to the claim or just leave the wheezing diagnosis as is.

Or is there another option?
How about using Z76.0 to cover the refills? If he did not give status or do anything to assess the conditions for which the refills are given, I would not code those.