Wiki Not sure about DX

[Radcoder86]

I'm coding an encounter for a patient that came in for temporary disability paperwork plus foot pain. The doctor for diagnoses put, work stress, insomnia and depression related to work stress, and pain in foot. I'm thinking it should be coded as Z02.71 (encounter for disability paperwork), Z56.6 (other physical and mental strain related to work), and M79.671 (R foot pain). Is it okay for me to code it this way since he didn't put down disability exam as a dx?

Thanks!

 

[Amy Pritchett]

The patient may have presented for the disability paperwork, however the physician must state within the body of the progress note the reason the patient is being seen. I would only list the diagnosis that he submitted within his documentation. You could also have him provide an addendum to state the reason the patient was seen in the encounter/admission.

 

[Radcoder86]

Well, he did list it as the CC, he just didn't put it down under the list of dx's....