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You must always review the documentation to determine the correct code. From what you have provided there is no way to determine the correct code.
 
Thanks. That's the problem I'm having, though. We don't get the chart, just the fee sheet. I'm struggling with the way things are done. I'm new and hesitant to say too much. We're doing lots of back billing...
 
That is unfortunate and leads to problematic issues but the dx code reflects the patienbt's condition for that encounter and we must always be correct on that as it transnmits infor,ation to the payer for ,uch more than just reimbursement. So as to your original question, there can be no answer and no code without a chart note and no one can correctly advise you as to a correct answer otherwise. I hope you are able to get this system changed, until then I feel you cannot be coding anything.
 
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