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JustCoding News: Outpatient, March 21, 2012

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Given the limited physician documentation on outpatient records, are coders coding long term use of anticoagulants, aspirin, etc., from a medication form alone?

For example: Patient is seen in 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 V codes 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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