jnieto625
Networker
In reviewing a note, I queried my provider on the following because she assigned an asthma code but based on her documentation it seems like the dx is not definitive.
Assessment & plan
Asthma - The patient has allergies and does have wheezing associated he does not have an official diagnosis of asthma but it seems very likely to be reactive airway disease. He is using Symbicort on a daily basis at night. Ventolin only as needed
I informed her of the coding guidelines and she came back stating: He was not wheezing at the visit, just reported it although not frequently so I didn't use it in ROS
either (because it says frequent wheezing). He is taking medication for asthma (symbicort) so I am going to assume it is asthma even though I don't have confirmation.
I am now questioning whether I should assign the code or not because the note still says that he does not have an official diagnosis and that it is "likely". Any feedback would be greatly appreciated.
Assessment & plan
Asthma - The patient has allergies and does have wheezing associated he does not have an official diagnosis of asthma but it seems very likely to be reactive airway disease. He is using Symbicort on a daily basis at night. Ventolin only as needed
I informed her of the coding guidelines and she came back stating: He was not wheezing at the visit, just reported it although not frequently so I didn't use it in ROS
either (because it says frequent wheezing). He is taking medication for asthma (symbicort) so I am going to assume it is asthma even though I don't have confirmation.
I am now questioning whether I should assign the code or not because the note still says that he does not have an official diagnosis and that it is "likely". Any feedback would be greatly appreciated.
