Wiki Diagnosing visits

[MorganDodson34]

If a diagnosis is in the "chief complaint" example: "Chief Complaints: finger pain and RA"
BUT is not listed elsewhere in the note, can the RA be diagnosed?

Most of my providers will make statements such as "patient is here for fu for rheumatoid arthritis" and continue with note and findings.
One of the providers does not do this, the only mention of what is being discussed is in the "chief complaint". The provider will start a note as "patient is here today for 3rd visit" and continue on with findings ect, but not list an an actual reason. Is this sufficient for billing diagnoses?

Thanks in advanced!

 

[TThivierge]

Hi Morgan
Diagnosis or assessment need to be listed not good idea take dx out of chief complaint. Per auditing regs states follow up needs to add rationale on why coming in for follow up..which the one provider did correct. In the findings.... does the provider list RA and finger pain in later down on documentation...then be ok to list this as dx code.
I hope helped you
Lady T