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maryek28@outlook.com

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We have a new medical provider who does not state the diagnosis or symptoms in his notes. The diagnosis codes are selected by the provider from a drop down list on another page, but not stated in the documentation portion of the note. My job is to determine the level of E/M and I'm worried about what an auditor would think about the provider only selecting the dx codes from the list and not actually stating the dx in his documentation. Is this sufficient documentation for billing? Here is an example:

CHIEF COMPLAINT: Medication refill & follow-up

HISTORY OF PRESENT ILLNESS: Patient rates their overall health and wellness as positive vs. negative and they have no acute complaints or concerns at this time. They report eating a balanced diet, getting enough sleep each night to feel rested in the morning, and engaging in adequate physical activity throughout the week. They also report adherence to their medication regimen with no serious or life-threatening side effects or adverse reactions to their medications.

PHYSICAL EXAM:

--- GENERAL: Alert & oriented, in no apparent distress.
--- HEAD: Normocephalic with no obvious deformities.
--- EYES: Eyelids normal in appearance. No erythema of conjunctiva bilaterally.
--- ENT: External nares normal in appearance. Trachea midline.
--- RESPIRATORY: Symmetrical chest expansion. No dyspnea, tachypnea, increased WOB, audible wheezing. Lungs clear to auscultation in upper and lower lobes bilaterally.
--- CV: Normal HR and rhythm. No audible murmurs. No visible cyanosis.
--- MSK: Normal ROM and strength relative to sitting, standing, ambulation.
--- SKIN: No significant rashes, lesions, wounds visualized on exposed skin.
--- NEURO: No involuntary movements.
--- PSYCH: Appropriate affect & demeanor.

ASSESSMENT & PLAN:
--- Decreased sertraline from 100 mg to 50 mg, adding fluoxetine 20 mg. Will increased fluoxetine in 2 weeks to 40 mg if patient tolerates medication regimen.
 
You can't figure out the number and complexity of problems or even what the problem/condition is from this note. There is no assessment or diagnostic statement in this note. Why are they decreasing sertraline and adding fluoxetine? Is this the whole note/documentation for the encounter?
 
May I ask what EMR this is? Most of the ones I work with, the provider selects the dx from a drop-down, but it puts it into the encounter note.
You can make the case to the provider that an auditor wouldn't have access to "another" page, that all they get is the encounter note, and if there's no dx, there's no medical necessity for the visit. No necessity, no payment.
 
kdlberg said:
May I ask what EMR this is? Most of the ones I work with, the provider selects the dx from a drop-down, but it puts it into the encounter note.
You can make the case to the provider that an auditor wouldn't have access to "another" page, that all they get is the encounter note, and if there's no dx, there's no medical necessity for the visit. No necessity, no payment.
Click to expand...
We use Carelogic
 
amyjph said:
You can't figure out the number and complexity of problems or even what the problem/condition is from this note. There is no assessment or diagnostic statement in this note. Why are they decreasing sertraline and adding fluoxetine? Is this the whole note/documentation for the encounter?
Click to expand...
Yes, this is the entire note. The diagnosis codes are listed in a separate area that you have to click on to be able to see, but there is no statement of the diagnosis in the part the provider has to type out.
 
Yes, the diagnosis needs to be documented. There also needs to be a chief complaint. What medical condition is the patient seeing the provider for? To me its obvious that the patient is being treated for M/N condition/s, but this needs to be documented. If there is no documentation, there is no medical necessity. I agree with the above 100%. Amy is correct, there is no way to code this since you don't know if one medical condition is being evaluated or multiple conditions. This note is not codable.
 
Thanks everyone, I was pretty certain this documentation wasn't good enough, but I just needed others to back me up lol. I told the provider what needs to change but it's still not changing so I had to get supervisors involved 🤷‍♀️
 
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