Wiki Question about including certain diagnoses

[kimberagame]

Hello!

I'm wondering what you guys do when a provider spends their entire note talking about a particular issue, then in the assessment they include other issues that were never addressed. Sometimes it's because they're refilling meds for those other issues, but not always. These other issues have no comments regarding how the patient is doing regarding them. It's just the diagnosis and nothing else. Including these things could change the E/M level in some situations, and that's when I'm particularly hesitant to include them.

What do you guys do when you run across this? Thanks for any insights!

 

[mitchellde]

If the provider did not address these issues in the exam nor in the decision making process for the current problem then you do not code them. Many times the diagnosis listed under the assessment are appended by the software from the "problem list". You code only what is managed controlled or treated or those identified in the note as issues that complicate the management of the current condition.