Wiki Secondary To

[Michele1229]

Hello coders -

I am hoping you can help me. I code professional E&M for various specialties. Some of the providers like to list codes in their impression like I am going to show you below. These tend to stump me on what to order and then the order.
For example...
Patient with abdominal pain secondary to colitis.
Metabolic acidosis secondary to above.
Dehydration secondary to above.
Hypertension stable.

How would you code this? I don't know if I only code one, two or all.

Thanks!!!

 

[Reneeoleary]

Secondary to

If a symptom is secondary to a diagnosed condition, in this case colitis, then code the colitis not the symptoms. The hypertension is a separate condition and can be coded as a secondary diagnosis impacting care, if supported in the documentation. I hope that helps.