Can anyone provide me with back up on the following issue: I code lab and path for outpatient services. When determining diagnosis for the lab/path charges, can we pull from the ongoing problem list of conditions, if it is not supported in the note that the testing was done for that particular reason. My example is I had a Vit D screening done, with low vitamin d level R79.89 documented by provider in note and on orders. Patient in "ongoing problems list" shows VIT D deficiency. I used the R79.89 since it was documented and on orders from physician. Another example is routine wellness exam, patient had hemoglobin A1C performed, documentation uses z00.00 DM was not addressed in note but in ongoing problem list, they have DM. I did not add the DM diagnosis since the labs were screening labs. If it is not addressed in note, I do not feel it is a billable diagnosis, just because they had the ongoing/past medical history of the problem. Can anyone provide me with supporting documentation on this issue