Wiki Using Meds in Med Lists to Support Dx Coding

[jturcotte]

I'm interested in hearing people's thoughts on the idea of a coder using a Med List as support (or MEAT) for a dx listed in a problem list when there is no documented correlation in the note between the med and the dx. For example, if the problem list included Osteoperosis, and there was Vitamin D supplement in the med list, would you still code Osteoperosis even though the provider made no additional assessment/evaluation in the note, making the assumption that the provider is treating the osteoperosis with the Vitamin D supplement? I'm interested in opinions either way.

 

[erjones147]

I would not code off the med list unless your EHR requires that an assessment/indication accompany any ordered med (ours does). No med can be ordered or filled in our facility without a definitive dx from the ordering provider