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nklunk86

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I have come across a visit our provider did by phone with the patient. The HPI only says patient is here for HTN follow up. In the A&P the diagnosis dropped in are HTN and Hyperlipidemia and only thing documented is prescriptions and lab orders. There is nothing anywhere in the note about what was discussed during the visit or how the patient is doing. During a meeting yesterday a nurse said, "well as a nurse I understand what happened". But as a coder I feel there is documentation missing from the visit and fell as though if the insurance company looked at that it wouldn't be enough either. We keep getting told if a diagnosis is dropped in it was discussed even if there is nothing documented in the visit. Need some opinions and thoughts. TIA
 
nklunk86 said:
I have come across a visit our provider did by phone with the patient. The HPI only says patient is here for HTN follow up. In the A&P the diagnosis dropped in are HTN and Hyperlipidemia and only thing documented is prescriptions and lab orders. There is nothing anywhere in the note about what was discussed during the visit or how the patient is doing. During a meeting yesterday a nurse said, "well as a nurse I understand what happened". But as a coder I feel there is documentation missing from the visit and fell as though if the insurance company looked at that it wouldn't be enough either. We keep getting told if a diagnosis is dropped in it was discussed even if there is nothing documented in the visit. Need some opinions and thoughts. TIA
Click to expand...

"If it isn't documented, it didn't happen." - there's a reason why that phrase is so well-known. It's true!

The visit note is the legal record of what happened. If there was an audit or a lawsuit or any other review of the record, only what's clearly documented in the note will matter.

It sounds like there's an education opportunity for the nurse.
 
Per AMA guidelines from 2021, a medically appropriate history or examination is still necessary, I agree with True Blue above that the documentation must still be clear on what was discussed during the telephone encounter besides just dropping diagnoses and ordering tests. Additionally, CMS has rules on telephone encounters, making sure consent is documented as well.
 
I have a question that I cannot seem to get clear guidance on. IGRT images need to be approved by the Radiation Oncologist before their next treatment.

Images are taken the day of treatment and I would assume they need to be approved before that day's treatment. Not approved before "tomorrow's" treatment. All I can find is that vague statement stating "...before their next treatment". Any advice on how to advise my physicians?
 
christie.elam@epic-care.com said:
I have a question that I cannot seem to get clear guidance on. IGRT images need to be approved by the Radiation Oncologist before their next treatment.

Images are taken the day of treatment and I would assume they need to be approved before that day's treatment. Not approved before "tomorrow's" treatment. All I can find is that vague statement stating "...before their next treatment". Any advice on how to advise my physicians
Click to expand...

Hello! I just answered the question in your thread about the topic. If you need any additional clarification, please let me know!

 
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