Should Edema be coded

espforu

Guru
Local Chapter Officer
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NAPLES, FL
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Maybe I am having a brain fart! :)

The physician coded edema on the visit. The exam indicates "Extremities without clubbing, cyanosis, or pitting edema. It does document that the last visit he ordered Ted hose for edema but the patient did not comply with treatment. The documentation indicates "try ted hose bilaterally" Should edema be coded even though the exam is not indicating edema?

Thanks,
 

jwiles66

Networker
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Since edema is not documented it should not be coded. I would check with the physician for clarification before coding it.
 
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