Wiki Documentation compliance

[KoBee]

there is a provider whom doesn't seem to properly document currectly, or should say without a SOAP template.

Can someone review this example and let me know what they think. That is all the chart note says.


42-year-old is seen today for a follow-up to outline uterine fibroids. She delivered a child last month and a half she is here for a scanago she in for a scan - I did see sa pedunculated 4+ cm fibroid at the uterine fundus The uterus per Was normal in size -ovaries were normal -she is nursing and will continue on micronor A pap was also done

 

[luvbuix]

due to the new guidelines this area gets a little fuzzy! since we only now need either an MDM portion or a time statement to support a service the SOAP format is not required. although most practices still use that format you could actually just do a paragraph & be ok. i wouldn't call the above paragraph chock full of a lot of info but there is sort of a treatment plan there. per the AMA there should still be a "medically appropriate" hx, exam, & decision making. it's up to each individual to define "medically appropriate". i would educate this provider to build a better template with those components & a time statement here would be really helpful!!

 

[TThivierge]

Hi Kobee
As far as diagnosis codes I d use the following D25.9 or O34.13 (if had the tumor growth before birthing) since still under care. Also add dx last Z39.1 from notations above. If the mother is having problem with nursing, use the dx O92.79. Also use CPT 59430 if for postpartum care visit .
I hope this data helps you.
Lady T