Wiki Should Edema be coded

[espforu]

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]

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

 

[espforu]

Thanks, I though possibly I was correct, but sometimes I do second guess myself

 

[balamuruganm]

''No documentation Not to code''