Forum - Questions & Answers

Feb 25th, 2010 - lmariesmith 2 

diagnosis coding from Medical History

Can you code chronic conditions if listed in the medical history? For example: Provider is seeing the patient for URI and states in medical history "Reactive Airway disease, mild intermittent".

Feb 25th, 2010 -

you can

if they are addressed. Just listing does not count- so "reactive airway- mild intermittent" is ambiguous; it would be fine if it said "reactive airway-now mild, intermittent"

Mar 1st, 2010 - Codapedia Editor 1,399 

but be careful

If you look at the front of the ICD-9 book, there is a tiny section on the coding rules for physician services (outpatient, I think it's labeled.) Most of the introductory section applies to hospitals and diagnostics.

Only code services that are addressed that day, or that effected the MD"s treatment.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association