Wiki Which Dx to use with antimedics for the prevention of a condition?

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amber3452

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When an antimedic is given for the prevention Nausea / Vomiting can you automatically use the dx R11.2 even if the document does not support that the patient has Nausea/Vomiting in the medical note?
 
No, you can only assign a code for a condition that the provider has documented is present at the encounter - you can't make an assumption that just because a particular drug was prescribed that the patient has the condition that you think that drug is treating. If the provider hasn't documented a diagnosis or symptom or reason for the visit, then the documentation is deficient and should be returned to the provider for an addendum in order for you to assign a code.
 
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It's been YEARS since I coded chemo, and the guidelines may have changed, but I thought the antiemetics in absence of documentation of n/v are coded as cancer dx primary and encounter for chemo secondary.
I would imagine ASCO has some guidance on this subject.
 
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