Wiki Anemia coding

[kumeena]

Goodmorning everyone. TGIF


Primary care doctor writes his assessment plan anemia along with other diagnosis and refer the patient to hematology. Is it OK to add anemia in ICD 9 coding.He didn't mention on HPI or anyother place in the chart.

Thank you

 

[FTessaBartels]

How does he know patient is anemic?

How does he know patient is anemic? Are there labs noted?

Unless someone is using an EHR and dragging old material over, I usually take Dx from the assessment/plan area (might be called impression).

Would help to see the actual note.

F Tessa Bartels, CPC, CEMC

 

[kumeena]

Yes Tessa we are using Electronic chart. I think I am Ok to code anemia.

Thank you & Have a Nice weekend