Tonyj
True Blue
I believe this subject was previously discussed but I need a refresher. When coding charts I had used what may have been mentioned in the HPI as supporting diagnoses. Example: Pt presents for f/u to CML. Pt has multiple co-morbidities inclusive of HTN, diabetes, heart disease, kidney disease....
The A/P may mention only treatment regarding (chronic myeloid leukemia).
In the past I would include in the diagnoses the multiple co-morbidities mentioned in the HPI as well as the CML. Now, I've been told I could only use what the MD mentions in the A/P no matter whatever else was mentioned in the body of the report. Past forums responded as it is ok to use past surgical and medical history when coding diagnoses.
Am I wrong to include those diagnoses if they are not mentioned in the A/P? Or can I continue to use diagnoses found throughout the body of the report? Any assistance with corresponding documentation would be greatly appreciated.
The A/P may mention only treatment regarding (chronic myeloid leukemia).
In the past I would include in the diagnoses the multiple co-morbidities mentioned in the HPI as well as the CML. Now, I've been told I could only use what the MD mentions in the A/P no matter whatever else was mentioned in the body of the report. Past forums responded as it is ok to use past surgical and medical history when coding diagnoses.
Am I wrong to include those diagnoses if they are not mentioned in the A/P? Or can I continue to use diagnoses found throughout the body of the report? Any assistance with corresponding documentation would be greatly appreciated.