ICD 10 Coding Alert

ICD-10-CM Coding:

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

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 [...]
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