Hello! We have a scenario that seems grey to me and I appreciate any direction to be sure we are coding correctly.
One of our CC providers saw a patient for a separate condition, and the patient also asked that this provider refill her Januvia, Lantus and Norvasc. He also provided a rx for colostomy bags. The following is a screen shot from the HPI as the provider noted it. He also included the patient's current problem list directly under this:
"HPI: states was terminated by (our family med group) 2 mos ago for noncompliance with her care; does not have a PCP, and needs a refill of Lantus 20units once a day, Amlodipine 2.5mg once a day, Januvia 50mg 1/2 tablet once a day, and her colostomy bags (usually gets 4 boxes of 5 bags per box); also thinks that she may be developing a uti; no fever, no vomiting; allergic only to Abilify
Patient Active Problem List
• Bipolar affective disorder F31.9
• Acute pancreatitis K85.90
• Hypertriglyceridemia E78.1
• Anemia due to chronic kidney disease N18.9, D63.1
• Essential (primary) hypertension I10
• Chronic kidney disease, stage IV (severe) N18.4
• Diabetes mellitus E11.9
• Hypothyroidism E03.9"
From the Plan and Assessment:
"Encounter for medication refill
- insulin glargine (LANTUS) 100 UNIT/ML Subcutaneous Solution Pen-injector; Inject 20 Units below the skin every evening
- amLODIPine (NORVASC) 2.5 MG Oral Tab; Take 1 Tab (2.5 mg total) by mouth daily
- sitagliptin (JANUVIA) 50 MG Oral Tab; Take 0.5 Tabs (25 mg total) by mouth daily
I gave a hand-written rx for her colostomy bag, manufactured by Hollister; quantity 4 boxes of 5 bags/box, #8618"
My question is - are we "assuming" the dx codes to add to the Z76.0 if E11.9 and I10 are added to the provider's Z76.0, or is this documentation sufficient?
Thank you in advance for any responses.
Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.
1 post • Page 1 of 1