Wiki diagnosis section vs plan section

[tdsmitchell]

Our physicians are creating a diagnosis section separate from a plan section. The diagnosis section only contains two or three of the actual diagnosis. The plan section is littered with diagnosis however, it is titled "plan". Can we code from "plan" as well as the diagnosis sections?

this is an example of what we are seing.

diagnosis
chest pain
copd exacerbation

plan
acute copd exacerbation
severe cough
lll loss of volume
-oxygenation stable
-contin advair
-prior hx...
-cont meds
-d/c med
UTI
-levaquin
Chest Pain 2' cough
-antitussive...prn
Hypothyroidsm
Tachycardia
-EKG
Hyperglycemia
-likely ...

 

[FTessaBartels]

Diagnosis

I would just code what is in the diagnosis section. It seems that the physicians are trying to specifically identify the condition(s) being actively treated/managed at this visit.

Hope that helps.

F Tessa Bartels, CPC, CEMC