Wiki Fever as Symptom

[anne32]

I have a chart where the provider says the patient has flu-like symptoms so I am coding the actual signs and symptoms- body aches, nausea, cough, pharyngitis....My problem is the fever. It says tactile fever and doesn't say what the temp was or if the patient even measured it. The temp in the office is normal. Would I code the fever?

 

[mitchellde]

I would not code the fever it was not present at the time of the visit.