Wiki History and Impression

[Tonyj]

Physician stated in HPI for a follow up visit note "history is well characterized in my initial consult note dated xyz. Since last visit the pt feels......." The Assesment/Plan states "prostate cancer will proceed with chemo...."

The initial consult note stated the pt with prostate cancer, with bone, retroperitoneal and pelvic mets.

Question: Can I include the other diagnoses (i.e. METS) from the previous note onto this note for billing/scoring purposes even if it's not specifically stated in the present note? Or can I only include the Dx the physician stated in the present Assesment/Plan (prostate Ca)?

 

[ajs]

You can only use diagnosis codes for the condition the provider actually assessed and documented at that visit. You can ask the doctor to make an amendment to the note in order to add the documentation regarding the other condition if it was assessed and discussed at that visit.