Question Diagnoses not supported in Histories & Exam HELP needed!

debellis59

Networker
Messages
36
Location
Kennewick, WA
Best answers
0
I hope someone has some advice on this ...

We have a new provider, one who was the "coding documentation specialist" at another hospital/clinic system. Her notes will start out with a CC of back pain, she'll do an HPI related to the back pain, and ROS, exam, etc. The HPI will support a Level 3 visit, but then she'll add a LOT of extra diagnoses, stating what meds she's changing, how the patient is doing ... things generally contained in the HPI, ROS, Exam, etc ... but are only found in her Plan/Assessment. She states over and over that this is adequate to support a Level 4 service since she's document what should be in the HPI, ROS & Exam, in the P/A. Our Reviewer who is going to speak with this doctor tomorrow can't find anything stating that it needs to be addressed in the body of the note specifically and is saying now that she believes that the documentation of this information ONLY in the Plan/Assessment will be enough to support a Level 4 visit.

I guess I should state also (this is an edit) that she enters things such as Afib, CHF, ESRD, DM, etc, in the diagnoses (for a patient with Low Back Pain throughout the entire note) with info in the Plan/Assessment ... Afib on coumadin no changes, DM with neuropathy and insulin dosages adjusted, etc ... nothing about any of this in the rest of the note ... but expecting these to affect LOS.

I'm worried about this opening a can of worms with our other providers ... and about a potential audit.

Has anyone any links on this? Any support for the information being in the HPI, ROS, Exam, etc? I've yet to find anything that states it specifically, but it's what we always understood ... that diagnoses just can't be pulled in and, even though she's changing dosages, etc, for it to change the LOS.

HELP!
 
Last edited:

thomas7331

True Blue
Messages
2,897
Best answers
7
I'm not sure if I'm completely understanding your question, but I'll give it a try.

First, there is no requirement that information used toward an E&M code level be documented in a particular location or section of the note. Although it may be awkward documentation, it is perfectly fine for history and exam information to be documented in the assessment and plan section. As long as the documented elements in the note support the code description, there should not be a problem with this. The code should reflect the provider's documented work, not the organization or structure of the record.

As far as adding additional diagnoses, I don't know of any official guideline or regulation that requires E&M levels be based solely on conditions that are related to the chief complaint. (It may be a source of patient complaints if they are coming in for one thing and the providers are doing more than the patient is asking for, but that is a customer service issue, not a coding problem.) Providers always have to take into account the full picture of the patient's condition. As long as the documentation supports that those conditions were evaluated by or affected the provider's work, (for example as evidenced by the fact that the provider needed to make an adjustment to a medication) then they can and should be considered toward the determination of the level.

My recommendation would be to not challenge the provider on this, as it's not the coder's place to make a determination as to whether or not a particular treatment decision was warranted for the encounter - that is medical practice and not coding. Coding should be based on what is documented and it's always been my position that unless your organization has clinicians involved in guiding the coders on this in some way, coders must just stick to coding from what the provider has actually documented and not be second-guessing whether or not the work that is documented was really necessary or pertinent to the encounter.
 

csperoni

True Blue
Messages
720
Location
Selden
Best answers
2
I agree with Thomas. You get the credit regardless of where in the note the information is located.
I will note that I wouldn't challenge the provider, but I would educate the provider about how the documentation is done to make it easier for all. While the items can go under any heading, or even no heading, having them under the accurate heading makes it clear. Fewer coding inquiries. Less headache during audit. More accurate communication with other care providers. Less scavenger hunting to give the provider credit for the work they do. Sometimes you get a provider that doesn't want to do it that way, but sometimes it is just because they don't understand the additional problems it can create.
 

debellis59

Networker
Messages
36
Location
Kennewick, WA
Best answers
0
I'm not sure if I'm completely understanding your question, but I'll give it a try.

First, there is no requirement that information used toward an E&M code level be documented in a particular location or section of the note. Although it may be awkward documentation, it is perfectly fine for history and exam information to be documented in the assessment and plan section. As long as the documented elements in the note support the code description, there should not be a problem with this. The code should reflect the provider's documented work, not the organization or structure of the record.

As far as adding additional diagnoses, I don't know of any official guideline or regulation that requires E&M levels be based solely on conditions that are related to the chief complaint. (It may be a source of patient complaints if they are coming in for one thing and the providers are doing more than the patient is asking for, but that is a customer service issue, not a coding problem.) Providers always have to take into account the full picture of the patient's condition. As long as the documentation supports that those conditions were evaluated by or affected the provider's work, (for example as evidenced by the fact that the provider needed to make an adjustment to a medication) then they can and should be considered toward the determination of the level.

My recommendation would be to not challenge the provider on this, as it's not the coder's place to make a determination as to whether or not a particular treatment decision was warranted for the encounter - that is medical practice and not coding. Coding should be based on what is documented and it's always been my position that unless your organization has clinicians involved in guiding the coders on this in some way, coders must just stick to coding from what the provider has actually documented and not be second-guessing whether or not the work that is documented was really necessary or pertinent to the encounter.



Thank you. We won't force the issue. But we are going to ask her to please tie things together ... she's making statements such as "Patient sleeping a lot" and expecting us to tie it to Alzheimer's without any evidence of this being the case. My own mother died of Alzheimer's and rarely slept ... she walked morning, noon, and night. Kept everyone busy constantly. And we can't ASSUME causal relationships ... they must be spelled out. So she is being educated on this.

I do appreciate the response.
 

debellis59

Networker
Messages
36
Location
Kennewick, WA
Best answers
0
I agree with Thomas. You get the credit regardless of where in the note the information is located.
I will note that I wouldn't challenge the provider, but I would educate the provider about how the documentation is done to make it easier for all. While the items can go under any heading, or even no heading, having them under the accurate heading makes it clear. Fewer coding inquiries. Less headache during audit. More accurate communication with other care providers. Less scavenger hunting to give the provider credit for the work they do. Sometimes you get a provider that doesn't want to do it that way, but sometimes it is just because they don't understand the additional problems it can create.


Thank you. I did spell out on Thomas's email a bit of what we are needing to educate her on ... but we aren't going to challenge her. She is refusing to do it in a more traditional manner ... but we are asking her to tie seemingly unrelated things she is insisting ARE related. Telling her we can't assume a causal relationship and that the provider MUST provide that link.

I appreciate your response.
 
Messages
3
Best answers
0
I'm not sure if I'm completely understanding your question, but I'll give it a try.

First, there is no requirement that information used toward an E&M code level be documented in a particular location or section of the note. Although it may be awkward documentation, it is perfectly fine for history and exam information to be documented in the assessment and plan section. As long as the documented elements in the note support the code description, there should not be a problem with this. The code should reflect the provider's documented work, not the organization or structure of the record.

As far as adding additional diagnoses, I don't know of any official guideline or regulation that requires E&M levels be based solely on conditions that are related to the chief complaint. (It may be a source of patient complaints if they are coming in for one thing and the providers are doing more than the patient is asking for, but that is a customer service issue, not a coding problem.) Providers always have to take into account the full picture of the patient's condition. As long as the documentation supports that those conditions were evaluated by or affected the provider's work, (for example as evidenced by the fact that the provider needed to make an adjustment to a medication) then they can and should be considered toward the determination of the level.

My recommendation would be to not challenge the provider on this, as it's not the coder's place to make a determination as to whether or not a particular treatment decision was warranted for the encounter - that is medical practice and not coding. Coding should be based on what is documented and it's always been my position that unless your organization has clinicians involved in guiding the coders on this in some way, coders must just stick to coding from what the provider has actually documented and not be second-guessing whether or not the work that is documented was really necessary or pertinent to the encounter.
Thomas- Do you have an article I could reference regarding this? Your comments speak directly to a conversation I've been having with my providers and I would like to be able to share this with them in a more "official" format. Thanks in advance!
 

thomas7331

True Blue
Messages
2,897
Best answers
7
Thomas- Do you have an article I could reference regarding this? Your comments speak directly to a conversation I've been having with my providers and I would like to be able to share this with them in a more "official" format. Thanks in advance!
The 1995 and 1997 official guidelines are always the best starting point, if you can get the information you need by using those. But can you be a little more specific about what you're looking for? There are many publications about E&M coding and documentation guidelines out there, so what points in particular are you wanting to show your providers?
 

wisibyusha

Networker
Messages
97
Location
Cordova, Tennessee
Best answers
0
I believe that if she was a documentation specialist then she knows what to include and report in order to state the complete condition of the patient. You also agree that if a coexisting condition is being treated or managed during an encounter then that condition will be reported. As for the particular diagnoses you mentioned: Afb, CHF, DM, etc they all are HCCs and need to be captured once a year for risk adjustment and you cannot just list them, you have to have documentation about them in other words, the physician needs to follow the MEAT technique. That's why you see her documenting med. change. As for E/M leveling, the three components are history, exam, and mdm only for the CY 2020 for outpatient setting. How the physician handles the treatment and management will be in the mdm and perhaps that's why she says the LOS might change.
happy coding!
 
Top