Wiki Changing a diagnosis - evdience based

[hinditina]

I was reviewing a progress note where the patient came in for a follow on dm 2, htn, and low back pain. In the assement in plan the MD chosed 250.02 but there is no evidence of it being in out of control. no lab ref, no increase of medications, only a listing of what medications the patient is is currently on. doesn't reference if it was out control before in other visits. Just ordering labs.
I can't asked to adden the note it is already 30 days out. So I just changed it to 250.00 or leave it as 250.02 even though he doesn't state it?
Thank you for your opinion.

 

[kbazarte@yahoo.com]

I would pull the previous office notes for that dictation to see if it was 250.00 or 250.02. If it was 250.00 on the last visit I would query the physician to see what justified the change, it may have been an oversight or an accidentally coding error. Even though a amendded dictation is not possible at least the physician is made aware of any changes or errors and possibly a note can be added to the pt. record.