Documentation question

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I am a CDI working at a hosptial with HCC Medicare Advantage patients. Physicians concern were:

What is the best way to document chronic conditions that the patient has during a sick visit. An example was someone being seen for a cold. Where in the medical record should the conditions be documented when the patient is being seen for something else?


How does the PCP document a condition that is being treated by a specialist, example CHF. They wanted to know if it needed to be in the assessment and plan or if they could just put it in the HPI.

I believe I have the answers but wanted to double check. Thank you for your help!

Diane
 

TThivierge

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Best Way to Document Chronic Conditions

I am a CDI working at a hosptial with HCC Medicare Advantage patients. Physicians concern were:

What is the best way to document chronic conditions that the patient has during a sick visit. An example was someone being seen for a cold. Where in the medical record should the conditions be documented when the patient is being seen for something else?


How does the PCP document a condition that is being treated by a specialist, example CHF. They wanted to know if it needed to be in the assessment and plan or if they could just put it in the HPI.

I believe I have the answers but wanted to double check. Thank you for your help!

Diane
Hi
The provider could mention them but do not mention if that is not associated with the illness presented for the day. Ensure the doc uses Chronic vs Acute depending on patient illness if ongoing illness. They should use the MEAT method. M Monitor Evaluate Assess and Treat. M.E.A.T can be supported by asking about current meds, look at test results or do a physical exam. Also just a statement should be fine under the HPI if patient tells doc about past specialist on another issue. If it is past illness can be put in with Z history code which is on record for past illnesses but should not be plopped on the claim unless related to current illness.

I hope this info helps you
Lady T
 
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