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Wiki ongoing problems

Loleina00

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Martinez, CA
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Can you use diagnosis codes of ongoing problems for Medicare pts or only what is indicated for that DOS by the physician if you can't find anything? Thank you!
 
What do you mean "ongoing problems" are the Chronic conditions? Are these conditions that are being treated or assessed? Nevertheless you must still follow coding guidelines when reporting any dx regardless if it is a Medicare pt or not.
 
What I meant is that a physician will order labs for particular DOS but does not put down a payable diagnosis code, for instance a PSA test that he orders. But under problem list as ongoing problems, pt has BPH, which is a payable code for the PSA. Am I allowed to use a diagnosis under the problem list? I am new at this, so just inquiring. Thanks
 
No a coder cannot make a decision regarding the reason for a test based on the problem list. The provider must document whether this is a cancer screening or drug monitoring or to monitor the status of the BPH.
 
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