I would imagine he'd have to. A patient can have 428.0 (CHF) but there are different dx for that. It could be Systolic or Diastolic chronic or acute, or even acute on chronic. Without his documentation stating so, there is no way to be certain. If he wants credit, for say higher levels of E&M that meet medical necessity, then yes, he MUST document that the condition(s) were in fact chronic.
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