AudCo2020!
Networker
I am in need of clarification of the required documentation to code chronic conditions. If the CC states "F/U" and states "depression symptoms controlled, blood sugars low, HTN" and the plan states "continue on current meds, follow up in 1 month or prn" and includes lab results, can you code depression, DM, and HTN?
I am definitely thinking no, that each condition needs to be assessed and treated in order to code them. Such as "HTN controlled" or "HTN controlled on current medication" and likewise for the DM and depression. I know a coder can not interpret lab results. And as far as the plan goes; should it say something like "continue Metformin for DM" not just "continue current meds"?
I am looking for specific information of what needs to be documented in order to code all the chronic conditions.
I thank you in advance for all information!
I am definitely thinking no, that each condition needs to be assessed and treated in order to code them. Such as "HTN controlled" or "HTN controlled on current medication" and likewise for the DM and depression. I know a coder can not interpret lab results. And as far as the plan goes; should it say something like "continue Metformin for DM" not just "continue current meds"?
I am looking for specific information of what needs to be documented in order to code all the chronic conditions.
I thank you in advance for all information!