Internal Medicine Coding Alert

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


Alaska Subscriber
 

Answer: Ultimately, for you to report any condition or disease, the internist 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 internists 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).

Answers to You Be the Coder and Reader Questions reviewed by Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.