ICD 9 coding

There has been a discussion between our hospital and physician coders on the appropriate way the diagnosis should be coded for the physician services. When billing for the physician services (Medicare Part B) for an inpatient or observation patient, can the coder pull information from the prior or subsequent notes to code the diagnosis? For example, the patient is inpatient and on the admit H&P the physician states COPD with severe exacerbation but on day 2 the subsequent note states just COPD. Can the coder code COPD with severe exacerbation on the second day even though the note for this date does not state exacerbation?

I'll say yes

in this case. The diagnosis is not as important as the E&M code if you are worried about auditing. The patient is still being treated for a severe exacerbation that has improved so you can still use the severe COPD code. If I document "acute blood loss anemia due to duodenal ulcer with hemorrhage" on the first day to allow the hospital to code that as a CC or MCC (rather than just ulcer and anemia) and on day two I write ulcer and anemia, you can still use the codes since the disease did not change.

If the doc admits this COPD patient who also has diabetes and the doc's notes beyond the H&P never address diabetes then it is not appropriate to carry it forward for subsequent day visits.