Looking at clinics cardiac notes, I was presented with this question and would like to hear from other Cardiac coders who review physician notes. If the physician just list hypertension, hyperlipidemia, atrial fib up in the history part of the note do I always consider acute unless the physician specifies with these conditions? Is there a length of time considered when the condition moves to a chronic status. Our intentions are to try to improve the documentation with these conditions listed on the notes acute vs chronic but I want some good information to provide to them. thank you so much.
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Wiki chronic conditions in the history part of the exam
- Thread starter SSweetland
- Start date
mitchellde
True Blue
Actually if it is just listed in the history and not addressed in the exam or decision making area, you would not code it.
And if they do address the conditions by controlling their medications, EKG, etc could you look at these conditions as chronic without the physician being specific. I like when you post answers, you are very good.
mitchellde
True Blue
Thank you! And yes you would treat it as a chronic condition.
thank you, I will pass the message on.