Tamara314
New
We have many providers asking for ways to decrease the documentation burden for appropriate risk coding. They want to know if they can use a global or general statement in the Assessment and Plan in conjunction with the a list of diagnoses being used in the encounter. For example:
Assessment and Plan:
Medicare annual wellness visit, subsequent (Z00.00)
Moderate recurrent major depression (F33.1)
Paroxysmal atrial tachycardia (I47.1)
Essential hypertension (I10)
Mixed hyperlipidemia (E78.2)
Long term anticoagulants (Z79.01)
History of falling (Z91.81)
The patient has the above following chronic medical conditions, which all contributed to my decision making and the creation of the personalized prevention plan. No adjustments were made to the patient’s treatment plan during this visit, and we will follow up on these medical diagnoses in more detail at the next visit.
So here are my questions:
Assessment and Plan:
Medicare annual wellness visit, subsequent (Z00.00)
Moderate recurrent major depression (F33.1)
Paroxysmal atrial tachycardia (I47.1)
Essential hypertension (I10)
Mixed hyperlipidemia (E78.2)
Long term anticoagulants (Z79.01)
History of falling (Z91.81)
The patient has the above following chronic medical conditions, which all contributed to my decision making and the creation of the personalized prevention plan. No adjustments were made to the patient’s treatment plan during this visit, and we will follow up on these medical diagnoses in more detail at the next visit.
So here are my questions:
- Does anyone have providers who use this kind of documentation?
- Do y'all think this would pass a RADV audit?