Wiki Diagnosis Code from Exam

[anne32]

I have a chart where the patient complains of right ear pain. In the exam it says EARS: TMs:erythematous and bulging bilaterally. In the treatment/ assessment portion the provider states the patient has Otitis Media and Rx amoxicillin and gives instructions on meds and fever etc. My question is can I code this as bilateral OM since it is in the exam? Or does the provider need to spell it out in the assessment/treatment section?

 

[ehanna]

I have a chart where the patient complains of right ear pain. In the exam it says EARS: TMs:erythematous and bulging bilaterally. In the treatment/ assessment portion the provider states the patient has Otitis Media and Rx amoxicillin and gives instructions on meds and fever etc. My question is can I code this as bilateral OM since it is in the exam? Or does the provider need to spell it out in the assessment/treatment section?

That's how I would bill it. This is the portion the Physician documents so sometimes we have to further specify from these areas.

I hope this helps

Emily