samyjm13
Guru
I know that if it is not documented it didn't happen. But,,, a new patient comes in for establishing care and med. refills, provider addresses the reflux, allergies and prostate cancer in the note, addresses nothing else. Now in the Assessment the provider puts the following DX : Hyperlipidemia, depressive disorder, arthropathy, gall baldder colic. and of course the addressed DX. However, these DX I have mentioned that have not been addressed in the note, are in the PMH. My question is can I code them? We are having a bit of a difference of opinion here in our office. Can someone help with the our discussion?
Thanks, Jeanne
Thanks, Jeanne