General Surgery Coding Alert

Question: Can we code a condition or disease if the physician notes in the documentation that the patient is now on medication for said condition?


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Answer: Ultimately, for you to report any condition or disease, the physician has to state the diagnosis. If you aren't a physician, you cannot assume diagnoses based on test results or medications--you-ll have to ask the doctor.

For example, if you read in the chart that the patient is on valium, you can't assume she has anxiety because many physicians prescribe valium to relieve back spasms. Although your inferences may be educated and correct, if the physician doesn't explicitly state that diagnosis, you can't report it.

Remember: You should only report a condition or disease if it is the reason for the service or is a condition that will affect the physician's treatment of the patient (for the condition that's the reason for service).

Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.