Tuesday, October 6, 2015

Using Diagnoses From Prior Encounters

One of the most common questions we get is whether or not a diagnosis from an earlier encounter can be used for a current encounter.

Standard coding advice has always been that a diagnosis cannot be "pulled forward" to a new encounter. Coding Clinic, Q3, 2013 has addressed this issue.  In part, the Coding Clinic advice says:

"Conditions documented on previous encounters may not be clinically relevant on the current encounter.... However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation."

Coding Clinic indicated this advice applies to both ICD-9 and ICD-10 coding.  We hope this advice will clear up this frequent question.

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