Wiki Diagnosis coding from the notes?

[TLC]

If a doctor has NOT put in his "assessment" a diagnosis but it does show in the notes that he has addressed the problem. Is it ok for me to use that diagnosis code in the billing? So if the patient has HTN, sore toe and cough but only puts the assessment HTN and sore toe is it ok for me to add the cough to the charges for billing? This is what I have been told in the past that it is ok to do this. If this is so is there some documentation that shows this? Thanks for your help

ps. If there is a problem in the "active problem list" (which may not really be active anymore). Is it ok for a coder to use that for billing. If it was not addressed at all at the appt. I wouldn't think so because the "active problems" are not necessarily active now. Just usually come over from past visits. Someone said that they do that and I was just wondering.

Help please.

 

[erjones147]

You could take cough from other fields than the "assessment" block, but think of it this way - do you need the cough dx to justify a procedure?

Did the provider address the cough in any way, like with a lab order, med refill, or tx plan? If not, just leave it off

 

[TLC]

This is just a hpothetical question. Saying if a 99213 was done and yes he gave medicine but left off the dx of cough in the 99213 billing. Is it ok for med to add the dx of the cough being that is was in the notes?