Don’t Take Verbal Query Response as Part of Medical Record
Question: A patient presents for a regular appointment with the pulmonologist for a follow-up on asthma care. Their problem list includes hypertension, but the most recent encounter note does not mention it. The provider verbally confirmed during a chart query discussion that the patient has high blood pressure. Can I report hypertension based on the problem list and the provider’s verbal statement? Maryland Subscriber Answer: No, when coding diagnoses, coders need to rely on the provider’s documentation for the date of service of a specific encounter. A verbal statement alone does not support code assignment, and a problem list entry alone is generally not sufficient to report a diagnosis for a specific encounter without supporting encounter documentation. While a problem list may include conditions that are relevant to the encounter or reason for their visit, if they’re not mentioned in that encounter’s documentation, they do not automatically warrant inclusion. Similarly, a provider can provide verbal clarification but that alone does not support code assignment — the diagnosis/condition must be entered into the medical record via a signed addendum or a documented query response. In terms of compliance, diagnosis reporting must be supported by authenticated medical record documentation for the date of service. Coding without supporting documentation presents audit risk, as well as potential denials, overpayment findings, and allegations of inaccurate or unsupported coding. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
