# Uncertain or Definitive Dx



## jnieto625 (Apr 25, 2017)

In reviewing a note, I queried my provider on the following because she assigned an asthma code but based on her documentation it seems like the dx is not definitive.

Assessment & plan
Asthma - The patient has allergies and does have wheezing associated he does not have an official diagnosis of asthma but it seems very likely to be reactive airway disease.  He is using Symbicort on a daily basis at night.  Ventolin only as needed 

I informed her of the coding guidelines and she came back stating: He was not wheezing at the visit, just reported it although not frequently so I didn't use it in ROS 
either (because it says frequent wheezing). He is taking medication for asthma (symbicort) so I am going to assume it is asthma even though I don't have confirmation. 

I am now questioning whether I should assign the code or not because the note still says that he does not have an official diagnosis and that it is "likely".  Any feedback would be greatly appreciated.


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## mitchellde (Apr 25, 2017)

going by the documentation, the rules state you cannot code this as a diagnosis.


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## erjones147 (Apr 26, 2017)

I agree with Ms. Mitchell. I hate it when providers do this; we usually see it for transfer-of-care visits or for when a patient is just visiting relatives and wants meds for their vacations. Whenever I query the providers about giving a definitive diagnosis for meds (our tribal clinic can bill our state Medicaid for pharmacy encounters), I get back something like, "Well, I'm just treating symptomatically," or some such garbage


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