The patient is a 60 y/o male with CKD and diabetes with COPD.
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Get it written →Indicate if the medical documentation is complete. If the documentation is considered not complete, indicate what the provider needs to complete for an accurate code to be selected.
The patient is a 60 y/o male with CKD and diabetes with COPD. The patient is admitted due to an exacerbation of his COPD due to rhinovirus infection and is managed with respiratory support and monitoring of his other chronic conditions. During admission, a discovery of elevated blood pressure is made, and he is started on lisinopril. On day four, the patient is discharged with directions to manage his condition and return for a two-week follow-up.
Is this medical documentation complete?
If no, what documentation does the provider need to complete for an accurate code to be selected?
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