Wiki Seizure code

[TLC]

Hopefully someone has an idea. A patient comes in saying she had a "seizure" and has had a couple of episodes in the past. She also states she gets drunk a couple times a week. Also passes out. Oh, also smokes marijuana, New patient to the office so no evidence on our part that the patient has seizures. Can we code (780.39 seizure disorder) could we use (V12.40 disorder of nervous system)Help please. Thanks

 

[FTessaBartels]

The DOCTOR provides the diagnosis

The physician provides the diagnosis, not the patient. What did the physician document in the A&P portion of the note?

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[TLC]

seizure code

Well we have a problem, the doctor is asking me for a code, since I am the "coder"

 

[dclark7]

If you have no docuemntation from old records, I would just tell the doctor that you cannot code seizure disorder or history of. Why did the patient come to the office, if she is having symptoms you code code those. Or if the doctor has documented the alcohol and marujuana use you could code those problems.