Advanced Search

ICD 10 Coding Alert

ICD-10-CM Coding:

Don’t Take Verbal Query Response as Part of Medical Record

Published on Tue Jun 02, 2026

Question: A patient presents for a regular appointment with the pulmonologist for a follow-up on asthma care. Their problem list includes hypertension, but the most recent encounter note does not mention it. The provider verbally confirmed during a chart query discussion that the patient has high blood pressure. Can I report hypertension based on the problem list and the provider’s [...]
Codify by AAPC
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles in this issue of

ICD 10 Coding Alert

Subscribe to newsletter