ICD-9 codes throughout the note

[Love Coding!]

Hello,

I went to a workshop held by Ingenix last year and wanted to get a consensus on what others think. Does the diagnosis that are being billed need to be listed under the assessment and plan? I have some physicians that will list the diagnosis in the HPI sometimes or other areas of the note. Would I be considered too conservative if I instructed my physicians to only list the diagnosis under the assessment and plan or can they get away with listing them throughout their note?

Thank you,

 

[FTessaBartels]

HPI = patient / Diagnosis = physician

The HPI is what the PATIENT reports ... when did it start, where does it hurt, how did it happen, what makes it better, etc.

The diagnosis is what the physician - given his/her years of training and experience - determins is the disease/injury - DM2, sprained knee, fractured clavicle, abscess, etc.

Therefore it SHOULD be in the assessment/plan.

That being said, I do know physicians who document one long note with no subheadings and I have to figure it out. S I G H...

Hope that helps.

F Tessa Bartels, CPC, CEMC