Wiki Pull diagnosis from the exam

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Hello, I need a concensus on this please...

Can you pull a diagnosis to bill from the exam portion of the dictation in replace of stating it under impression?

Example:

Constiutional: Positive for malaise and fatigue
Cardiovascular: Positive for edema of the lower extemities

Can the physician bill for these, although he is not doing anything for them and not mentioning those diagnosis under the impression section of the dictation?

Thanks!
 
mitchellde said:
Are either of these things symptoms of the patient's diagnosis? Does it add anything to the patient's story?
Click to expand...

The physician only documented in the exam, he did not list these diagnosis in the HPI or under the impression. He found these during the examination and billed for them. The patient has hypertension and metabolic acidosis and he is also billing for those.

I have been told that you cannot abstract a diagnosis from the exam, it would have to be mentioned in the HPI and/or assessment in order to bill. I know this is pretty ambiguous, I apologize for that.

Thank you :)
 
You are allowed to pull a diagnosis that is documented by the provider as condition currently affecting the patient or one that is managed controlled or treated. If the malaise and fatigue are symptoms of the metabolic acidosis then no you do not code it as it is a part of a diagnosis already coded the same for the edema, if these are not symptoms of the rendered diagnosis then yes you may code it as a current ailment.
 
mitchellde said:
You are allowed to pull a diagnosis that is documented by the provider as condition currently affecting the patient or one that is managed controlled or treated. If the malaise and fatigue are symptoms of the metabolic acidosis then no you do not code it as it is a part of a diagnosis already coded the same for the edema, if these are not symptoms of the rendered diagnosis then yes you may code it as a current ailment.
Click to expand...

Thank you Debra, that was the answer I was looking for, have a great day! :)
 
Malaise and fatigue are two symptoms that can be related to any number of diagnoses. Are we able to "assume" that the patient's malaise and fatigue are a part of his hypertension and/or metobolic syndrome or could this be a new problem that needs to be addressed?

Just wondering
 
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