Wiki Multiple diagnosis codes in A/P

[tcogdell]

I have one physician who insists on having as many as 10-15 diagnoses listed in his A/P. He is only addressing 2-3 of these and additional 2-3 contribute to the treatment of what he's addressing. The remaining are followed/treated by PCP or other specialists and are not mentioned elsewhere in the note. Is there something in writing I could show him stating he doesn't need to document those that don't apply to his treatment?

 

[mitchellde]

The physician may document anything he/she wishes. You are not going to find anything that will tell you to limit the documentation in any way. However we code only those dx codes relevant to the encounter.