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ED Coding and Reimbursement Alert

READER QUESTIONS:

Rely on Doctor's Word for Diagnosis

Published on Mon Feb 28, 2005

Question: The physician's notes state, "Tonsilar swelling, fiery red, no exudate noted. Diagnosis is strep pharyngitis." Do I need lab results to back up this diagnosis, or is the doctor's evaluation enough?


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Answer: In this case, the physician has formed his clinical impression based on history and exam. You don't need laboratory tests if your emergency department physician definitively diagnosed the patient with strep pharyngitis. Go ahead and report ICD-9 code 034.0 for this diagnosis.
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