During an office visit the patient states, 'I have rheumatoid arthr…

Question

During an office visit the patient states, 'I have rheumatoid arthritis,' but the clinician documents joint pain for evaluation and does not confirm or assess RA. What is the correct coding approach?

Accepted Answer

Do not code RA from patient self-diagnosis alone without clinician confirmation or endorsement. — Patients are great historians of how they feel, but they're not the ones signing the claim. If the doctor didn't confirm or work up 'RA' and only documented joint pain under evaluation, you don't code the patient's label just because it was spoken.

Answer

Code rheumatoid arthritis because patient-stated diagnoses always override the assessment.

Answer

Code RA and add a Z code indicating the patient is unreliable.

Answer

Always query for every patient-stated condition even when the clinician documented a different working diagnosis and declined RA.

During an office visit the patient states, 'I have rheumatoid arthritis,' but the clinician documents joint pain for evaluation and does not confirm or assess RA. What is the correct coding approach?

Short Explanation

Full Explanation