tci General Surgery Coding Alert - 2006 Issue 4

READER QUESTIONS: Wait for Diagnosis to Report Code

Question: Can we code a condition or disease if the physician notes in the documentation that the patient is now on medication for said condition?Alaska Subscriber Answer: Ultimately, for you to report any condition or disease, the physician has to state the diagnosis. If you aren't a physician, you cannot assume diagnoses based on test results or medications--you-ll have to ask the doctor.For example, if you read in the chart that the patient is on valium, you can't assume she has anxiety because many physicians prescribe valium to relieve back spasms. Although your inferences may be educated...

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