Wiki Facet arthropathy

[mhughes0301]

Good afternoon, I am having some feedback with providers on their audits. Does facet arthropathy listed as a diagnosis AUTOMATICALLY give a MODERATE problem? Or does the EXAM itself need to back up that facet arthropathy on that date?

Thanks for your help

 

[carlystur]

The diagnosis by itself does not give you a specific level of problem until you know how bad the problem is. Is the problem resolved, resolving, staying the same, or getting worse? That's why you see on the E/M Leveling table: Chronic Stable Problem (not causing problems), Chronic Problem with Exacerbation (problem is still an issue for the patient or feels a little worse), or Chronic problem with Severe Exacerbation (patient feels much worse).

 

[amyjph]

Nothing automatically gives a "moderate problem". As stated above, it has to meet the number and complexity of problems addressed. Someone could have facet arthropathy and zero problems with it or they could be in severe pain. Simply having a diagnosis code listed doesn't really do anything for the E/M unless the documentation supports leveling the E/M MDM or Time with regard to that diagnosis.

You can have chart notes that have fifteen different diagnoses listed which have been carried forward or auto populated and maybe one of those was the only thing addressed on the service date.