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Dx documented in the A/P

N

nlbarnes

Expert
Messages
292
Location
Escondido, CA
I have a provider that doesn't document a diagnosis in the A/P. I've asked him to document and he wants the guideline from CMS that this is required. He feels that it can be in any part of the progress note. I cannot find on the CMS website anything to support my request. Can anyone please provide the CMS link?
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He is correct, there is no such requirement. You do not have to mandate the Dx in the assessment and plan; I've seen the diagnosis indicated in the history and/or exam. It's preferred if the Assessment and Plan state the "problem/status/treatment", which helps you determine MDM, but you can abstract a diagnosis from anywhere in the note that is documented/signed by the provider.
 
Pam Warren said:
He is correct, there is no such requirement. You do not have to mandate the Dx in the assessment and plan; I've seen the diagnosis indicated in the history and/or exam. It's preferred if the Assessment and Plan state the "problem/status/treatment", which helps you determine MDM, but you can abstract a diagnosis from anywhere in the note that is documented/signed by the provider.
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Hello,
What about if the dx is nowhere in the actual chart note?
I am looking for some solid guidance that doesn't use terms like "medical record" because that term seems to be thought of as the "whole" medical record in my case.
Do you know where it says that EACH note needs to have the dx please?
 
stephanieyard82 said:
Hello,
What about if the dx is nowhere in the actual chart note?
I am looking for some solid guidance that doesn't use terms like "medical record" because that term seems to be thought of as the "whole" medical record in my case.
Do you know where it says that EACH note needs to have the dx please?
Click to expand...


If you're coding an E&M visit, then without a definitive diagnosis, you would code symptoms pulled from the HPI.
 
Hi, if there is a chief complaint (trouble sleeping, anxiety, change in appetite, etc) you can code based on that. If the note indicates the reason for the visit ("patient continues to complain of insomnia" "patient reports they no longer feel depressed all of the time") you could code based on that. Whether or not a payer will accept it is another issue.

If nothing in the note indicates why the patient received the service, you'll need to explain to the provider that they haven't established medical necessity, therefore you can't report a service, and the provider won't get paid.

You might also need to speak to them about the need to document in a way that allows you to report the most specific diagnosis possible. Payers are unlikely to keep paying on a symptom code even if they do cover it for the first few visits.
 
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