Wiki would you code from...

[arizona1]

Office note lists several "Medical Problems" under "Current Problems". No further mention of the dx and nothing listed in "Current Medications" list to support the dx listed.

Is the "Current" indicating the provider is addressing the problem? Is it correct to code from Current Problems, Medical Problems, if not stated again anywhere in the note?

Thank you.

 

[mitchellde]

I would not code anything that is not addressed in the assessment nor is a known comorbidity. No medications to treat it, no assessment for it, no plan to address it, I say no code for it.