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Additionally, supporting documentation should identify: The medication name The condition being treated Whether the therapy is ongoing Whether the medication is prophylactic or therapeutic Any medication monitoring performed during the encounter For example, a provider documenting “Type 2 diabetes controlled on long-term insulin therapy” clearly supports assignment of both E11.9 and Z79.4

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Dinh Tran, MD at Family Health Care At Family Health Care, your well-being is our top priority