Wiki assessment vs. diagnosis documentation

[Brenda1973]

Hello! please help. My provider is stating that his definitive diagnosis is UTI . I feel that he needs to remove the "symptoms consistent with" as that phrase is no longer allowed according to outpatient coding guidelines updated in 2020. The green highlight use to be the "Assessment" in the SOAP note but he has deleted the word assessment and added his diagnosis there and again in yellow as his final diagnosis. Please advise me as the guidelines state "consistent with" is not valid for a final definitive diagnosis. Can it be documented in the body of the note? can it be documented in the assessment and still use as a final diagnosis? My understanding has always been that the assessment is where we find the final diagnosis, so with that documentation in the assessment I would not be able to use UTI. I need a documentation expert here! Thanks!

 

[cjhalk@yahoo.com]

In the outpatient setting, terms like “consistent with” indicate an uncertain diagnosis and aren’t reportable as confirmed; in those cases we’d code signs/symptoms. The final diagnosis can be documented anywhere in the note as long as it’s clear and supported. For context: “consistent with/compatible with” were explicitly added to the uncertain terms list in FY2020 and remain excluded for outpatient coding today. If the only wording is “symptoms consistent with UTI,” code signs/symptoms. This is my take anyway.

 

[Brenda1973]

In the outpatient setting, terms like “consistent with” indicate an uncertain diagnosis and aren’t reportable as confirmed; in those cases we’d code signs/symptoms. The final diagnosis can be documented anywhere in the note as long as it’s clear and supported. For context: “consistent with/compatible with” were explicitly added to the uncertain terms list in FY2020 and remain excluded for outpatient coding today. If the only wording is “symptoms consistent with UTI,” code signs/symptoms. This is my take anyway.

Thank you, that is my take as well. I just dont know how to get it through to this provider. Im starting to doubt myself, hence why I am on here asking others. I have told him twice and sent him the CMS 2020 updated guidelines that state this terminology cannot be documented. He still disagrees and he built the phrase into the AI Nabla component so now all of our providers are documenting this! idk what to do other than involve a coding auditor for confirmation.

 

[rachaelwilleford]

I would explain it another way. If he is audited, documentation was requested, or if an authorization is required, the note will not substantiate medical necessity (meaning no authorization for the patient), and he could be subject to reduced payment, authorization denials, and recoupments due to lack of supporting documentation. Sometimes providers think that they understand the guidelines better than coders do, but they don't understand the implications.

 

[amyjph]

Depends on the full note for the specific encounter. There is a section showing "final diagnosis" there in your snip and it says UTI, urinary tract infection, uncomplicated. Is that the final diagnosis? The commentary above that in the snip, to me, is indicating that because the symptoms are consistent with a UTI, despite the absence of dysuria, the patient is being diagnosed with a UTI because of the frequency and sensation....
There can be places in the note where they sort of explain and indicate what they are seeing. I don't see a problem here. But there would be a problem if every single note is cloned and says the same thing for UTI. And/or if there is never a lab run for it. Depends on the full picture. If we took 25-30 notes from the provider, do they all have this problem?

 

[Cynthia Hughes]

I agree with Amy. This physician is showing the complexity of medical decision-making (ie, deciding to diagnose UTI and prescribe antibiotics despite absence of dysuria) for this visit that has a stated diagnosis of UTI. The language you reference is not within the diagnostic statement but rather the physician's assessment notes regardin how the diagnosis is supported. Cindy

 

[shanamarie]

Thank you, that is my take as well. I just dont know how to get it through to this provider. Im starting to doubt myself, hence why I am on here asking others. I have told him twice and sent him the CMS 2020 updated guidelines that state this terminology cannot be documented. He still disagrees and he built the phrase into the AI Nabla component so now all of our providers are documenting this! idk what to do other than involve a coding auditor

Thank you, that is my take as well. I just dont know how to get it through to this provider. Im starting to doubt myself, hence why I am on here asking others. I have told him twice and sent him the CMS 2020 updated guidelines that state this terminology cannot be documented. He still disagrees and he built the phrase into the AI Nabla component so now all of our providers are documenting this! idk what to do other than involve a coding auditor for confirmation.

It’s hard without seeing the full note, but if this phrase is being used for all notes for UTI then I would maybe recommend to the provider to just switch out the word “consistent with” to “supports”.