EricRmi
New
Good Day!
I just want to ask if it is fine to report ICD10CM codes from Chief Complain and HPI?
Because there were times that the Doctor is not documenting the sx or dx codes that will support the CPT procedure code.
Example: Patient is having stomach aches due to confirmed gastritis. It is treated by GI Cocktail. Doctor also wrote Breathing treatment and it was performed on that same patient.
However he did not write that the patient has Asthma and shortness of breath. But in the Chief complaint, the MA wrote that the patient also complains of SOB.
I wanted to report SOB code but it is not a confirmed sx by the Doctor.
I am a new Medical Coder and still getting experience.
I just want to ask if it is fine to report ICD10CM codes from Chief Complain and HPI?
Because there were times that the Doctor is not documenting the sx or dx codes that will support the CPT procedure code.
Example: Patient is having stomach aches due to confirmed gastritis. It is treated by GI Cocktail. Doctor also wrote Breathing treatment and it was performed on that same patient.
However he did not write that the patient has Asthma and shortness of breath. But in the Chief complaint, the MA wrote that the patient also complains of SOB.
I wanted to report SOB code but it is not a confirmed sx by the Doctor.
I am a new Medical Coder and still getting experience.