tci ED Coding & Reimbursement Alert - 2005 Issue 3

READER QUESTIONS: Rely on Doctor's Word for Diagnosis

Question: The physician's notes state, "Tonsilar swelling, fiery red, no exudate noted. Diagnosis is strep pharyngitis." Do I need lab results to back up this diagnosis, or is the doctor's evaluation enough?Hawaii Subscriber Answer: In this case, the physician has formed his clinical impression based on history and exam. You don't need laboratory tests if your emergency department physician definitively diagnosed the patient with strep pharyngitis. Go ahead and report ICD-9 code 034.0 for this diagnosis. ...

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