# coding pneumonia



## samyjm13 (Jul 14, 2010)

provider dx pneumonia, no labs, no xrays, can pneumonia be coded or just signs/symptoms. Pt has cough, fever, chills, sob especially when coughing. 

???????


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## cheermom68 (Jul 14, 2010)

*pneumonia*

If the provider gave the dx as pneumonia, that is what I would code.


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## mitchellde (Jul 14, 2010)

samyjw said:


> provider dx pneumonia, no labs, no xrays, can pneumonia be coded or just signs/symptoms. Pt has cough, fever, chills, sob especially when coughing.
> 
> ???????



A physician is allowed to diagnose infective conditions based on the clinical presentation of the patient with no confirming studies being performed.  So if he states pneumonia then it is, same with UTI, Otitis media, Sepsis, Strep.


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