Wiki diagnosis from chart

[solocoder]

OK, I know that I can not code a dx from a patient's chart, or their previous visit, but can I use that code if the doctor has pulled if from the chart? For example: if DM is not mentioned anywhere in the history, but the doctor lists it in his assessment, can it be coded?

 

[MnTwins29]

OK, I know that I can not code a dx from a patient's chart, or their previous visit, but can I use that code if the doctor has pulled if from the chart? For example: if DM is not mentioned anywhere in the history, but the doctor lists it in his assessment, can it be coded?

Was it addressed at all during the visit - meds, counseling, ordering or reviewing blood sugar labs, etc? If so, then yes, it can be coded.

 

[solocoder]

Thanks!