Documentation Query

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North Houston I think.
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My docs think if they list the chronic problems on an OV note that is all they need to bill that code that day. Don't they have to at least say they assessed a problem or discussed with patient at the visit?
 

lburke31

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Per ama," a chronic disease treated on an ongoing basis my be coded and reported as many times as it is applicable to the patients treatment. Or, when it affects the complexity for an acute problem, it should also be reported." hope that helps
lburke cpedc
 
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4,466
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Milwaukee WI
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Code only what was addressed

You should code only those issues that were addressed in the encounter.

For example - if I have HTN, but come in for a splinter in my finger, and there is no evidence of evaluation of my HTN (no med changes, etc) then you code only the injury to the finger.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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