debellis59
Networker
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!
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!
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