I have a provider who addressed a hypertensive episode that the patient experienced during their encounter- but the provider did not assign a diagnosis code for it...
Basic question: if documentation supports a problem addressed, but the provider DOES NOT assign a visit diagnosis for it, should we calculate that condition into the medical decision making of the level of service?
Basic question: if documentation supports a problem addressed, but the provider DOES NOT assign a visit diagnosis for it, should we calculate that condition into the medical decision making of the level of service?