Wiki A/P- With little information

[bethdeak]

Hi all, I wanted to get your feedback.

I have a provider that is noting an extended HPI, and Comprehensive exam, then under Assessment and Plan, just stating the diagnosis with the ICD-10 code.


For example, if the doctor is seeing the patient for Sinusitis or dizziness the assessment states:

J32.2 Chronic Sinisitis

R42 dizziness

Sometimes there is nothing else, no notes, orders or expansion in the note anywhere.

Very occasionally there may be an order for an xray or MRI.

I'm not seeing a true assessment and plan, giving their findings on how they got to the diagnosis. There is a disagreement going on that noting the diagnosis that way should count for a point- because it's noted. I feel like shouldn't they expand on it in some fashion? Showing their medical decision making? Impressions to score the risk?

Anyone had a provider like this in the past at all and have suggestions?

 

[Chelle-Lynn]

I would direct the provider to a very easy to understand tool on the CMS website in regards to evaluation and management documentation. I have provided the link below. But here is the back up you need:


General principles of medical record documentation apply to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, these general principles help ensure that medical record documentation for all E/M services is appropriate:

The medical record should be complete and legible.The documentation of each patient encounter should include:

Reason for the encounter and relevant history, physical examination findings,and prior diagnostic test results
Assessment, clinical impression, or diagnosis
Medical plan of care
Date and legible identity of the observerIf the rationale for ordering diagnostic and other ancillary services is not documented, it should be easily inferred Past and present diagnoses should be accessible to the treating and/or consulting physician

[FONT=Arial,Arial]Appropriate health risk factors should be identified
[/FONT]The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented
The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record

To maintain an accurate medical record, document services during the encounter or as soon as practicable after the encounter.

https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf

 

[bethdeak]

Thank you!

I just wanted to be sure I wasn't going a little crazy with this!