# Documentation for diagnosis



## maine4me (Jan 17, 2014)

I am currently performing an audit for one of our family practice physicians.  I am finding that there are many issues with the diagnoses in the body of the note versus what is listed in the diagnosis list. Our EMR works in such a way that the diagnosis codes in this list are transmitted to the charge entry staff for billing.  

I need clarification on the following: if a diagnosis is in the diagnosis list, but was not addressed in the body of the note, assessment and plan, exam, or HPI, then it should not be billed for on  this date of service? Right?

Also, if  patient is instructed to take continue taking Vitamin D in the plan for osteoporosis, then it would be inappropriate to code for Vitamin D deficiency since it is not documented in this visit?  Right?


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## MnTwins29 (Jan 17, 2014)

maine4me said:


> I am currently performing an audit for one of our family practice physicians.  I am finding that there are many issues with the diagnoses in the body of the note versus what is listed in the diagnosis list. Our EMR works in such a way that the diagnosis codes in this list are transmitted to the charge entry staff for billing.
> 
> I need clarification on the following: if a diagnosis is in the diagnosis list, but was not addressed in the body of the note, assessment and plan, exam, or HPI, then it should not be billed for on  this date of service? Right?
> 
> Also, if  patient is instructed to take continue taking Vitamin D in the plan for osteoporosis, then it would be inappropriate to code for Vitamin D deficiency since it is not documented in this visit?  Right?



Per ICD-9 Official Coding Guidelines, for co-existing conditions, one should "code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care, treatment or management."    So, if this diagnosis on the diagnosis list is not treated at this visit, but is documented to have affected patient care (i.e. cannot give a certain med because of condition X) then yes, it should be included.  

In your second question, I would not code the Vitamin D deficiency as it was not documented, as I am assuming, only the osteoporosis.

(side question: is this from the ROS? past history?  Just what is the "diagnosis list" on your EHR?)


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