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Topic Title: long term (current) drug use Outpatient coding
Topic Summary: Long term (current) drug use Outpatient services
Created On: 11/02/2011 02:52 PM

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 11/02/2011 02:52 PM
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jpetersen7635

Posts: 10
Joined: 06/02/2010

Are Outpatient coders picking up Long term (current) drug use from Medication reports alone?
Given the limited physician documentation on Outpatient records, are coders coding long term use of anticoagulants, aspirin, etc from a Medication form alone?

Example: Patient is seen for a pacemaker clinic to check the function of the pacemaker. The physician documents a diagnosis of rapid heart rate. The medication form shows that the patient is on an anticoagulant and aspirin.

Given the expansion of Vcodes to include codes for long term drug use, because of the significance of drug therapy's influences on the management of patients, would it be appropriate to code this information from a Medication form alone?
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 03/14/2012 09:29 PM
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SandyF

Posts: 28
Joined: 09/13/2005

Hi there,
I do not use the medication record since that is not documented by physician. So I only pick up meds that are on physician documented records such as the H&P, pre-op anesthesia record, etc.
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 03/21/2012 03:17 PM
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sheryl.crossman@providence.org

Posts: 1
Joined: 03/21/2012

It is our policy to code the V codes for long term drug use if the physician documents it. Or if the physician documents that he has reviewed the medication list. Or documents, see medication list.
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 04/11/2012 09:03 AM
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PEMC-CODERS

Posts: 1
Joined: 04/11/2012

It's our policy--on outpatient/ED charts--to code only what is "co-signed" or acknowledged by the physician. This includes the medication list. (Providence Everett)
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