Chronic Systemic Diseases

mjcstone

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High Point, NC
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Should Diabetes and Hypertension be counted in the Number of Diagnoses and Management Options and Table of Risk? We are auditing Cardiology and several patients have these chronic systemic diseases which are listed ONLY in the Active Problems list. They are not in the Assessment, Impression or Plan. Should we still give the provider credit for considering these diseases even though they are not mentioned in the note? :confused:
 
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