Re: coding section I

[Rnlncoh]

In a message dated 2/27/04 6:00:49 AM Eastern Standard Time, [EMAIL PROTECTED] writes: Hi, I have a question for the group. I have a patient that is diagnosed with clinical Pneumonia.He is symptomatic and receiving antibiotics.No chest x-ray was done.How would you code in section I. Pneumonia or respiratory infection? Thanks If the physician dx the pt with pneumonia &./or the order for the ATB states it is for pneumonia, then code it pneumonia.  If you don't have these things in place, then ask the MD to write a note to clarify the dx.  Either way, there has to be something in writing that states what the pt is being tx for and it would have to state pneumonia or respiratory infection.  Plus there are apparently symptoms being documented.  Need a clear picture with a dx and then code it.   Sherri