Wiki Coding when "history" has been marked

[torresreb]

I have a record I am coding where the patient has the following conditions:

hypertension
hyperlipidemia
Old MI and
Diabetes

The provider filled out the assessment and treatment plan (medication list also is noted for all the conditions) however I believe the provider mistakenly marked the 'history' box. History suggests that the patient's conditions have been resolved. The provider is no longer with us therefore a correction to the record cannot be made.

Am I able to code the conditions and ignore the history box since the assessment and treatment plan was completed?

 

[Amber]

history

Look at the medications the patient is currently taking.
Is the hypertention, hyperlipidemia, and diabetes being treated with any meds?
If so, yes code them.
Code for Old MI is 412.

 

[torresreb]

yes the patient is taking medications for all the conditions listed and the provider notes in the assessment and treatment plan that the conditions were under control because of the medication ... thank you for your help!!