Answer to Question #297826 in English for Danaisha

Question

John has been seen by Dr. Victor. As you look at the medical record in preparation for coding the diagnosis for today, you see that Dr. Victor has not provided a diagnostic code that would uphold the need for the procedures to the insurance company. From past diagnoses, you see that there have been diagnoses that could be used. What should you do?b

Answer 1

The conditions listed in the past medical history should not be included on the claim form by the coder. In order to include the condition on the claim form, there should be documentation in the history of the present illness or the assessment and the plan that the condition was addressed at the encounter.I should follow the ICD-10 guideline that states:

“Code all documented conditions that coexist at the time of the encounter and require or affect patient care or treatment.