vendredi 21 août 2015

Coding when "history" has been marked

I have a record I am coding where the patient has the following conditions:

hypertension
hyperlipidemia
Old MI and
Diabetes

The provider filled out the assessment and treatment plan (medication list also is noted for all the conditions) however I believe the provider mistakenly marked the 'history' box. History suggests that the patient's conditions have been resolved. The provider is no longer with us therefore a correction to the record cannot be made.

Am I able to code the conditions and ignore the history box since the assessment and treatment plan was completed?


Coding when "history" has been marked

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