Wiki Diagnosis Help

[Gemini18]

I have a physician who is writing his diagnoses as "same yesterday". I spoke to him about this and his answer is "you should know what that means". Well, DUH -- what if Medicare request the day of service for 6/10/08 and not 6/9/08, what would he do?

 

[donsqueen]

Try showing this to your provider:

To ensure that medical record documentation is accurate, the following principles should be followed:
•
The medical record should be complete and legible.
•
The documentation of each patient encounter should include:
o Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results.
o Assessment, clinical impression, or diagnosis.
o Medical plan of care.
o Date and legible identity of the observer.

I found this at http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

As I often see here: kick him in the bucks.

 

[LTibbetts]

Tell your boss that the golden rule for coding is "If it isn't documented, it didn't happen". We are taught that from day one when coding anything. I know how hard it is when dealing with people like that. Hang in there and just keep running him over with information proving your fact!!