Originally Posted by lgoram 
Per our physician, he states that on a visit that we can pull diagnoses from medication lists and active problem lists even if he does not assess or document
anything to do with those diagnoses. For example, he states to look at a medication and pull down the diagnosis that goes with it as a current diagnosis
for that patient for that day even though it was not discussed on that visit. I am of the understanding that if something was not discussed or documented
it cannot be coded. Please help.
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Coding History