m.matos@chcfl.com
Contributor
Hi,
My providers are arguing the documentation requirements. Because the ICD 10 code will appeal on the progress note with full description: for example: Acute suppurative otitis media, right ear, recurrent. They are arguing that they do not have to else where document in the progress note because the description of the of the diagnosis shows on the progress note and this should be enough. I strongly do not agree with this. I think it should be documented in the HPI, ROS, Exam or past medical history. Can someone please advise if I am right or wrong in my thinking? I need to be able to go back to the providers and advise that I have consulted AAPC on this.
My providers are arguing the documentation requirements. Because the ICD 10 code will appeal on the progress note with full description: for example: Acute suppurative otitis media, right ear, recurrent. They are arguing that they do not have to else where document in the progress note because the description of the of the diagnosis shows on the progress note and this should be enough. I strongly do not agree with this. I think it should be documented in the HPI, ROS, Exam or past medical history. Can someone please advise if I am right or wrong in my thinking? I need to be able to go back to the providers and advise that I have consulted AAPC on this.