In the DG for 1997 under "Number of dx or Mgmt options it states:
The number of possible diagnoses and or the number of mgmt options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.
DG: For each encounter an assessment, clinical impression, or diagnosis shouldl be documented. it may be explicitly stated or implied in doucmented decisions regarding management plans and/or further evaluation.
Were these problems ( htn, lipids) addressed or considered in the providers management options.
Hope this helps.
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