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Wiki Documentation Plan of Treatment

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djnall

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Cocoa, FL
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In the assessment, the physician documents DM type II with periph Circ manifestations and peripheral angiopathy in disease and for treatment, he indicates continue with diet and no change. He does not address either in the review of systems or in the PMH, patient is not on meds for either, and no tests have been ordered. Can we code these 2 diagnoses?
 
It doesn't say. Says Progress Note. No HPI, Exam shows vitals taken, lung clear, neurological - decreased response to tactile stimulation in lower extremities.
 
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