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Dx code from HPI/ROS

  1. #1
    Default Dx code from HPI/ROS
    Medical Coding Books
    When coding notes, if the MD doesn't include diagnoses from the HPI and/or ROS in the Impression/Plan is it justifiable to include them?

  2. #2
    Default Dx code from HPI/ROS
    If the provider only mentions the diagnosis my question is how did he treat the diagnosis?
    did he identify the status; did he/she discuss any type of plan; did he/she examine the relavant portion indicated. If one only mentions a disease and did nothing about it then the record speaks for itself--nothing was done - nothing is given.
    Pluto2349

  3. #3
    Default
    Quote Originally Posted by Gwendolyn Darrell View Post
    If the provider only mentions the diagnosis my question is how did he treat the diagnosis?
    did he identify the status; did he/she discuss any type of plan; did he/she examine the relavant portion indicated. If one only mentions a disease and did nothing about it then the record speaks for itself--nothing was done - nothing is given.
    e.g. Pt being seen for f/u cancer. HPI/ROS oral thrush given rx by pcp, hypertension given meds by other md. Impression/Plan: Hold chemo, complete course of rx, see other md for hypertension.

  4. #4
    Default
    In this case, I guess we should code cancer primary dx and you can add others as secondary dx because cancer is what doc is following up and treating. I guess doc is an oncologist too.

    HTH.
    Girish Dadhich, CPC

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