Wiki Active problem diagnosis code vs assessment line in EHR documentation

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smurray

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As part of our EHR system we have an active problem section that lists the pertinant diagnosis codes for a particular visit. Is this section compliant/sufficient for the care given including xrays or does there need to be an assessment line documenting the pertinant diagnosis.

For example, patient is being seen past the 90 day global for xrays of a total hip. Please reply as soon as possible.
 
My physician wants to use the dx code 715.95 that is in the active problem tab of the medical record and not dictate an assessment line in the medical record. According to CMS documentation guidelines an assessment line is a requirement of the medical record.
 
If the patient had a total hip replacement then they no longer have an active dx of osteoarthritis in the hip, and you go not use that dx any longer. If the reason for the encounter is follow up the you use a V67 code for follow up and a V code for joint replacement status. So I guess to answer your question given the circumstance you have cited you would not use an active dx that no longer exists. You need to use the reason for the encounter which in this case is a follow up.
 
I understand your reasoning for not using the DJD of the hip code any longer but insurance companies will not pay for visit or xrays using the V43.64 code alone. If they are not symptomatic but just returning for status update per doctors protocol, which code would you use?
 
The V43 code is a secondary only allowed code you need to use the V67 code first. You absolutely cannot use a dx code for a problem the patient no longer has or is not being seen for. The dx is the patient's not the provider's and you must always be correct in the code selection for the documentation. Your documentation supports this patient is here for follow up following a hip replacement and that is what the claim must reflect.
I hate to harp on this but we must really use the correct codes no matter what. The integrity of our profession demands no less.
 
I am sorry I was not questioning your integrity at all just giving you good arguments to use with your provider. There is an extreme avoidance of the V codes and I do not understand why. Again I apologize if I offended you that was not my intention
 
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