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Established visit, Doc states in the HPI that the has a diabetic foot ulcer, neuropathy, ASHD and obesity.  The assessment states only diabetic foot ulcer.  I also code the above diagnoses because they are associated problems.  The HPI is expanded and the exam detailed.  Since he didn't actually include them in his assessment, can I count the neuropathy and ASHD in the Table of Risk under moderate as 2 or more chronic problems (in addition to the DM) and also under number of diagnoses/management options as 5 as they are all stable?
kmrjpr

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Reply with quote  #2 
When you say the physician didn't bring the other diagnoses down to assessment, how do you know they were stable?

Physician's cannot just put CAD stable and consider that condition addressed or treated.

Similarly when they are listing chronic conditions in HPI they cannot just say CAD, ASHD, obesity, diabetes and consider that 3 or more chronic conditions were addressed.  The actual guideline states we need to see the status of the condition, which means more than just stable.  An example of a condition that is stable and being addressed is:  CAD stable on aspirin, continue follow up with cardiology.

so--is there anything else in the note that indicates the other conditions were somehow addressed, treated, monitored.  Obesity on exam is like BP readings for HTN.  They are just comments and not a treatment or plan.  

And to count those as comorbidities that are impacting the current treatment, the physician needs to link it somehow and tell us HOW they impact.  For example in a diabetic patient with cough--patient is diabetic, recommend using sugar free Robitussin for cough.  That links the diabetes to the cough and shows us how it's impacting current conditions.

We cannot assume the other conditions were impacting the care and treatment of the diabetic foot ulcer without the physician telling us how they impacted.  Think about it this way--how is obesity a problem for the foot ulcer?  We don't know unless the physician tells us how. 

I would NOT count the other conditions as treated and would not report, would not give credit in HPI or exam/MDM.  To me, based on what you have below, all he treated was the diabetic foot ulcer.  
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