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diagnosis section vs plan section

  1. #1
    Default diagnosis section vs plan section
    Medical Coding Books
    Our physicians are creating a diagnosis section separate from a plan section. The diagnosis section only contains two or three of the actual diagnosis. The plan section is littered with diagnosis however, it is titled "plan". Can we code from "plan" as well as the diagnosis sections?

    this is an example of what we are seing.

    chest pain
    copd exacerbation

    acute copd exacerbation
    severe cough
    lll loss of volume
    -oxygenation stable
    -contin advair
    -prior hx...
    -cont meds
    -d/c med
    Chest Pain 2' cough
    -likely ...

  2. #2
    Milwaukee WI
    Default Diagnosis
    I would just code what is in the diagnosis section. It seems that the physicians are trying to specifically identify the condition(s) being actively treated/managed at this visit.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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