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Wiki HPI items not addressed

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lgiusti

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Good Afternoon Everyone,

CC: medication refill

HPI: Patient here for medication refills. Pt has type 2 DM, HTN, HLD, GERD. Patient reports poor compliance with meds and out of BP meds about 2 wks.

Of note; Lisinopril, Metformin and issue of repeat prescription for Prilosec. Controlled on current medication dose and regimen.

Would you consider the following a true statement in regards to this scenario?

"You must document the conditions you didn't address (eg; HLD and chronic pain not addressed during this encounter")

Thank you for your time
Lyn
 
From a purely coding standpoint, I would not consider that a true statement - coding guidelines don't state this anywhere that I know of, and also don't have jurisdiction over what a doctor must or must not document. I think this is more of a clinical documentation quality type of issue than a coding one, but even then I'm not sure that not documenting that a provider did not address a condition would be a serious problem.
 
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Tom, I totally agree. Just trying to get the point across to the coding team. Your quick response and feedback is much appreciated.
Respectfully, Lyn
 
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