History of

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Provider documents:

Patient has a history of iron deficiency, chronic kidney disease, and an elevated alk phos level, all of which will need rechecked. She also is due to have cholesterol checked. Recheck lab work at this time.

Provider codes as current conditions not history of. Would you code these as history of or query to find out if they are actively treated and if so ask the doctor to make a correction to the documentation.
 

Pam Brooks

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That looks like information in the HPI. What did he/she say in the assessment/plan? That is where you should code from.

Look at the med list. Is the patient on Vitamin D supplements? CKD doesn't go away, so you'd never code history of, it's a current condition, and likely the patient is on some sort of diuretic. Is the patient being treated with statins? Then the hypercholesterolemia is active.

Then go back to provider and explain the concept of 'history of'. Ask him to give you a definitive diagnosis in the assessment.
 
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