Wiki Systemic Conditions

[mpl5btx]

Should systemic conditions be coded on office visit encounters if they are listed on a problem list within the doctor's notes? The doctor does not say anything about the conditions in his documentation nor does he put them in his assessment, they are only listed on a problem list.

Thanks

 

[jewel30956]

i think if the dr doesn't mention it or provide any treatment for the condition then you don't have to code it. If the condition is the underlying cause of the office visit then yes. Other than that no.