Wiki PRN Medication Orders

[clcutting]

I get confused when it comes to coding from PRN orders. How do you code from PRN medication orders?
A diagnosis is documented as part of a PRN medication order.
a. The diagnosis can be coded from the order itself
b. If the same diagnosis is documented elsewhere in the record, it can be coded
c. The diagnosis can only be coded if the nurse gave the medication
d. The diagnosis can never be coded, regardless of where else it was documented
Any help is appreciated

 

[thomas7331]

I'm a little confused by your question - what do you mean by 'coding from PRN orders'. What service are you coding a diagnosis for? Facility or professional? You would not normally code a diagnosis from a PRN order but from the physician's own documentation.

Remember that the diagnosis is associated with the encounter, not with the drug. The code should be reported if the provider has documented that the condition is present at the encounter, and if it meets the criteria as a reportable diagnosis as per the ICD-10 guidelines (e.g. the condition requires evaluation, treatment or monitoring during the encounter).

 

[clcutting]

I'm a little confused by your question - what do you mean by 'coding from PRN orders'. What service are you coding a diagnosis for? Facility or professional? You would not normally code a diagnosis from a PRN order but from the physician's own documentation.

Remember that the diagnosis is associated with the encounter, not with the drug. The code should be reported if the provider has documented that the condition is present at the encounter, and if it meets the criteria as a reportable diagnosis as per the ICD-10 guidelines (e.g. the condition requires evaluation, treatment or monitoring during the encounter).

Ok, the service is for an inpatient facility, which I'm new with inpatient coding. Thanks for the clarification.