Forum - Questions & Answers
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".
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"
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.