Wiki Auditing EHR Medical Decision Making containing only DX Codes

[shellott]

We have a new EHR and in-order to make everything go smoothly the progress note must have actual ICD-9 codes in the documentation, in the EHR.

I review notes, and provide education feedback to the doc's. However, I'm not sure how to proceed with this since I've never come across it before. The assessment and Plan in the providers note(s) has ICD-9 codes as their assessment and plan. So, their note will have HPI, ROS, Exam than ICD-9 codes for the assessment and plan.

This is their decision making process and they have determined the patient has the problem. However, I am used to reading an assessment and plan to determine the level of service and the diagnosis of the patient.

Is it appropriate to have a progress note which only has ICD-9 codes as the assessment and plan?

Any feedback will be helpful.

 

[CIROD]

Assessment ICD9 codes

Does anyone have an answer to this question?????

 

[missy874]

We currently code from our EHR and had the problem of the provider putting the problem list as their assessment and plan (list ICD9 codes). Our coding team came up with the policy that we would only count those diagnoses if they had a statement that showed MDM. Stable, improved, change Rx etc. There must be some editing by providers to support that they are either evaluating or managing the problems.