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Using Meds in Med Lists to Support Dx Coding

  1. Default Using Meds in Med Lists to Support Dx Coding
    Medical Coding Books
    I'm interested in hearing people's thoughts on the idea of a coder using a Med List as support (or MEAT) for a dx listed in a problem list when there is no documented correlation in the note between the med and the dx. For example, if the problem list included Osteoperosis, and there was Vitamin D supplement in the med list, would you still code Osteoperosis even though the provider made no additional assessment/evaluation in the note, making the assumption that the provider is treating the osteoperosis with the Vitamin D supplement? I'm interested in opinions either way.

  2. Default
    I would not code off the med list unless your EHR requires that an assessment/indication accompany any ordered med (ours does). No med can be ordered or filled in our facility without a definitive dx from the ordering provider

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