# Dx code from HPI/ROS



## Tonyj (Aug 16, 2011)

When coding notes, if the MD doesn't include diagnoses from the HPI and/or ROS in the Impression/Plan is it justifiable to include them?


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## Gwendolyn-Darrell (Aug 16, 2011)

If the provider only mentions the diagnosis my question is how did he treat the diagnosis?
did he identify the status; did he/she discuss any type of plan; did he/she examine the relavant portion indicated.  If one only mentions a disease and did nothing about it then the record speaks for itself--nothing was done - nothing is given.


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## Tonyj (Aug 16, 2011)

Gwendolyn Darrell said:


> If the provider only mentions the diagnosis my question is how did he treat the diagnosis?
> did he identify the status; did he/she discuss any type of plan; did he/she examine the relavant portion indicated.  If one only mentions a disease and did nothing about it then the record speaks for itself--nothing was done - nothing is given.



e.g. Pt being seen for f/u cancer. HPI/ROS oral thrush given rx by pcp, hypertension given meds by other md. Impression/Plan: Hold chemo, complete course of rx, see other md for hypertension.


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## dadhich.girish (Aug 16, 2011)

In this case, I guess we should code cancer primary dx and you can add others as secondary dx because cancer is what doc is following up and treating.  I guess doc is an oncologist too.

HTH.


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