How far can coders clinically infer?
say my doctor diagnosed the patient with bipolar disorder depressed and in the notes it says " patient endorses auditory hallucinations but refused to share context"
seeing that, it needs more clarification right? because it will be unspecified-
and under problem list it says bipolar disorder depressed F32.9 < the fact that it says that in the notes, it should be billed as is even though there is little documentation that encounter can be billed with higher level of specificity if there is clinical knowledge and if it’s documented accordingly?
F31.31 Bipolar disorder, current episode depressed, mild
F31.32 Bipolar disorder, current episode depressed, moderate
F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features
F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features