I am new to coding Psychiatric inpatient charts and I was told to code all "history of" diagnosis that the nurses have pulled from a patient's old records and put on the face sheet (s/p hysterectomy, appendectomy, gallbladder removal, cataract removal).
The doctor is not documenting the majority of the "history of" diagnoses in his current physician orders which is where I code from.
Also the doctor documents an up arrow lipids. He doesn't document hyperlipidemia so I was told not to code this. Any clarification would be appreciated.
The doctor is not documenting the majority of the "history of" diagnoses in his current physician orders which is where I code from.
Also the doctor documents an up arrow lipids. He doesn't document hyperlipidemia so I was told not to code this. Any clarification would be appreciated.
