Overcoding?

Tonyj

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I believe this question was posed before but I could use a definitive answer and where I may be able to find it in writing.

I code stem cell transplants for cancer patients. In the A/P there can be upwards of 10 or more diagnoses. Is it necessary to list all diagnoses as listed by the physician for billing purposes? See below for example:

IMPRESSION: xxxxxx is being followed for the following problems:

1: Follicular NHL. There is no evidence of recurrent disease. No restaging studies are obtained. These are due later this month.
2: PTLD-associated plasma cell dyscrasia. He has decreasing monoclonal protein. No adenopathy is noted. Restaging studies will be obtained at the end of April.
3: Hematological. Blood counts are as noted. His platelet count has fallen and he will receive a platelet transfusion under my supervision today. The persistent cytopenias are believed to be a result of virus and/or medication.
4: Infectious disease. He has persistent CMV reactivation with a rising CMV level. The CMV resistant testing shows resistance of all three available agents. I discussed this situation with him. The ID consultant recommends admission to the hospital for full-dose Foscarnet administration. Mr. xxxxx notes that he did not clear his virus with that treatment in the past. He is a candidate for CMV hyperimmune globulin and we will request insurance approval for this. We are exploring enrollment into clinical studies at Baller in Houston, Texas and Memorial-Sloan Kettering in New York. It is unlikely that DLI will be of effect in that his donor is CMV negative. We will continue with a taper of immunosuppressive medications.
5: GVHD. He is being treated for a clinical diagnosis of chronic GVHD involving the skin and, possible, gut. He is on an accelerated steroid taper. Tacrolimus is decreased to 1 mg every other day. He will continue with sirolimus.
6: FEN. He is receiving magnesium supplementation. His weight is stable.
7: Hypertension. His blood pressure is under adequate control.
8: Hypogonadism. He will continue Androderm supplementation. A testosterone level can be repeated later this month.
9: GI. He has persistent nausea. This could be related to medications or to GVHD. If his symptoms remain minor, he will be withdrawn from the immunosuppressive medications.
 
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