Wiki Dx documented in the A/P

[nlbarnes]

I have a provider that doesn't document a diagnosis in the A/P. I've asked him to document and he wants the guideline from CMS that this is required. He feels that it can be in any part of the progress note. I cannot find on the CMS website anything to support my request. Can anyone please provide the CMS link?

 

[Pam Warren]

He is correct, there is no such requirement. You do not have to mandate the Dx in the assessment and plan; I've seen the diagnosis indicated in the history and/or exam. It's preferred if the Assessment and Plan state the "problem/status/treatment", which helps you determine MDM, but you can abstract a diagnosis from anywhere in the note that is documented/signed by the provider.

 

[stephanieyard82]

He is correct, there is no such requirement. You do not have to mandate the Dx in the assessment and plan; I've seen the diagnosis indicated in the history and/or exam. It's preferred if the Assessment and Plan state the "problem/status/treatment", which helps you determine MDM, but you can abstract a diagnosis from anywhere in the note that is documented/signed by the provider.

Hello,
What about if the dx is nowhere in the actual chart note?
I am looking for some solid guidance that doesn't use terms like "medical record" because that term seems to be thought of as the "whole" medical record in my case.
Do you know where it says that EACH note needs to have the dx please?

 

[Pam Warren]

Hello,
What about if the dx is nowhere in the actual chart note?
I am looking for some solid guidance that doesn't use terms like "medical record" because that term seems to be thought of as the "whole" medical record in my case.
Do you know where it says that EACH note needs to have the dx please?

If you're coding an E&M visit, then without a definitive diagnosis, you would code symptoms pulled from the HPI.

 

[stephanieyard82]

Hello,

This is for psychotherapy visits, and they are also not including any symptoms.
Thank you for any help you can offer.