Does a problem count as a problem addressed if it … Q: If the provider sees a patient for a specific illness and refills a medication for a chronic […]
What constitutes a well-documented record? A coder’s perspective Q: The new AMA guidelines for 2021 state that the nature and extent of the history and/or physical […]
Diagnosis coding for coexisting diabetes, hypertension, and chronic kidney disease Q: My clinician is asking which condition should be coded as causal to chronic kidney disease – hypertension […]
History of Present Illness in 2021 Q: Should we continue to require HPI information for each problem in 2021? A: Answer: While we are […]