Wiki Transplant complication code

[Tonyj]

Patient has GVHD after bone marrow transplant. For diagnoses purposes can I use the complication to transplant code with the GVHD code even though the MD did not specifically state complication of transplant in his note? ICD9 suggest using complication code with GVHD code.

 

[johnmeyer]

I wouldn't. I'd go back to the doc first to ask him/her to put the complication in the chart note first. It's like one of my professors said.... Document, document, document because if you don't, it didn't happen and you're going to get into trouble if you don't.