It depends on the documentation - of course.
Your main complaint is the cancer ... and it is NOT worsening unless the physician specifically states that it is. It is stable or improved.
Chemo is not a complaint, any more than any other medication/treatment is a complaint. However, side effects of the treatment may be a complaint. So if the patient is complaining of nausea, night sweats, dizziness, etc those may be considered separate problems (if they are actually being addressed, and not just listed).
And any one of these side effects may be a "new" problem if it's the first time the patient is complaining of them.
It all depends on the documentation.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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