Wiki DX in the assesment/treatment part of the note

[Kimberly Suarez]

if a patient comes in and has 5 conditons listed in HPI for ex: CHF, CKD, HTN,HLD and GERD....the provider pulls each one of those conditons into his assesment and plan- he only addresses CKD and HTN at the visit that day- should he remove the rest of the DX from his assesment and plan ?

 

[thomas7331]

I've seen providers do this and I don't know that there's any need to have that information removed. The provider likely feels that it's important to document that these conditions are present even if he is not directly addressing them at the visit, and it shouldn't have any impact on how the encounter would be coded or reimbursed.

 

[Kimberly Suarez]

I've seen providers do this and I don't know that there's any need to have that information removed. The provider likely feels that it's important to document that these conditions are present even if he is not directly addressing them at the visit, and it shouldn't have any impact on how the encounter would be coded or reimbursed.

thank you for the response