Wiki Visit Diagnosis vs. Problems Addressed - MDM

[deajsharichardson]

I have a provider who addressed a hypertensive episode that the patient experienced during their encounter- but the provider did not assign a diagnosis code for it...

Basic question: if documentation supports a problem addressed, but the provider DOES NOT assign a visit diagnosis for it, should we calculate that condition into the medical decision making of the level of service?

 

[csperoni]

Unless it's a policy of the facility/employer, a clinician does not need to assign diagnosis CODES. The clinician does need to indicate what the diagnosis is, but does not have to pick the most appropriate code for it. A coder (or any other person qualified to do so) may translate the diagnosis words into the codes, and assign those codes in your billing system. If the documentation supports the physician diagnosing and treating a hypertensive episode, I would have no issue with assigning the diagnosis code and calculating that work into leveling the visit.