Wiki Using previous dx or chronic illnesses w/o doc

[t.rock.tara]

Could anyone tell me if a doctor (PCP) is allowed to diagnose previous or chronic illnesses without documentation in a follow-up visit?

Also if they simply write these diagnosis under assessment but do not elaborate patients problem is that appropriate to use as a diagnosis on your superbill for billing?

Example : Hypertension when the patients B/P was 124/68 with patients weight being 237 lbs.

I appreciate any help or insight! Thank you!

 

[em2177]

Under ICD-9 guidelines, a diagnosis cannot be coded unless it is stated in the current visit documentation.

Once established, a chronic condition must be restated each time it is assessed or treated. A diagnosis cannot be carried over from one visit to another.

Hope this helps.

 

[t.rock.tara]

Thanks so much for your help!