E/M Coding Alert - 2011 Issue 3
Reader Questions: You Will Need a Diagnosis Code for a Feigned Illness
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Article Overview
This article addresses a coding question from a short new-patient office encounter where the documented presentation raised concern about possible feigning of illness alongside a reported pain complaint. It is written for coders and clinical documentation staff who need to understand how the reported documentation affects diagnosis selection and encounter coding at a broad level, without substituting for the full guidance in the premium article.
Why This Topic Matters
Encounters involving questionable symptom presentation can create documentation and diagnosis-selection uncertainty. The article helps readers understand the kind of documentation review and coder-provider communication that may be relevant when assigning codes for a brief evaluation visit.
What You Will Learn
- How documentation can affect diagnosis-code selection in a short office encounter
- Why coder-provider clarification may be relevant when the documented presentation is uncertain
- How a brief encounter with a reported pain complaint may be framed for coding review
- General considerations when suspicion of feigned illness is documented
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation staff
- Billing staff
- Physician and non-physician practitioner practices
Codes Discussed
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