# Using previous dx or chronic illnesses w/o doc



## t.rock.tara (Jul 17, 2009)

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!


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## em2177 (Jul 17, 2009)

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.


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## t.rock.tara (Jul 17, 2009)

Thanks so much for your help!


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