Wiki Chronic Condition Documentation


Port Richey, FL
Best answers
Hello. I wanted to get an opinion on this senerio. I do coding for an outside facility from which I dont have access to all of the patient's records. I just have the encounter to work from. In your opinion, if I have a patient with several chronic conditions, and the patients meds are not listed on this encounter, and what was stated was "reviewed patients medical records currently stable." I feel that this is still addressing the chronic conditions, as they are going to be permanent conditions. My coworkers think otherwise. I would like to have the meds listed on this encounter but the meds to treat all the conditions are not listed in documentation. What is your take on this? I feel its a fine line, but still feel the condtions are addressed and the chronic condion should be coded. Thank you for your input.