becka95
Networker
I understand that the "problem list" is a tool that is used for meaningful use. However, I am running into issues with information that was provided to my company which was passed down to physicians that the problem list is the list of diagnosis that are being used for that encounter. I work for a company that handle multiple wound care centers and the diagnosis can change from one visit to another but not always. I have tried to explain to the staff and trainers that each visit stands alone and that the documentation needs to support the diagnosis and treatment rendered during that visit.
the EHR company has told physicians that the problem list is supporting documentation and it flows to the electronic superbill. As a coder, my responsibility is to review the documentation, query the doctors for clarifications and code based on the documentation provided. I am constantly removing their diagnosis that flowed over from the problem list and adding the codes that are appropriate for that encounter. Usually the diagnosis that the physician has on the problem list is not documented at all in the chart not even in the medical history. Other times, the documentation supports a more specific code than the one in the problem list.
I do NOT change the codes in the problem list due to company policy. I only change the diagnosis on the superbill since this is not part of the chart.
Does anyone have a reference stating that the problem list is considered supporting documentation for coding? My understanding is that the problem list is a tool for the staff and other care provider to exchange key clinical information. It also lists specific conditions for quality improvement. But I cannot find anything that states it is used for coding.
I have tried to send a problem list change list and sent charts back because the problem list diagnosis is not documented. This is extremely time consuming for both me and the physicians. The physician are not willing to update the problem list or documentation to support the diagnosis in the problem list.
I have no idea where to go to find this information. Obviously the EHR company is not the place to go because they are the ones who told the Dr's that it is supporting documentation. Please help!
the EHR company has told physicians that the problem list is supporting documentation and it flows to the electronic superbill. As a coder, my responsibility is to review the documentation, query the doctors for clarifications and code based on the documentation provided. I am constantly removing their diagnosis that flowed over from the problem list and adding the codes that are appropriate for that encounter. Usually the diagnosis that the physician has on the problem list is not documented at all in the chart not even in the medical history. Other times, the documentation supports a more specific code than the one in the problem list.
I do NOT change the codes in the problem list due to company policy. I only change the diagnosis on the superbill since this is not part of the chart.
Does anyone have a reference stating that the problem list is considered supporting documentation for coding? My understanding is that the problem list is a tool for the staff and other care provider to exchange key clinical information. It also lists specific conditions for quality improvement. But I cannot find anything that states it is used for coding.
I have tried to send a problem list change list and sent charts back because the problem list diagnosis is not documented. This is extremely time consuming for both me and the physicians. The physician are not willing to update the problem list or documentation to support the diagnosis in the problem list.
I have no idea where to go to find this information. Obviously the EHR company is not the place to go because they are the ones who told the Dr's that it is supporting documentation. Please help!