Wiki I'm having a hard time explaining

[Sarah Ann]

We share the same EHR with other practices. I was informed that everything from the EHR is considered documentation because the physician signs the final encounter note, this includes problem lists, medication lists info. that nurses collect (not BMI, or pressure ulcer stages etc.). Nothing on those lists ever ends up in the note itself. How can this be documentation if it's not in the encounter note on the DOS? To me it's what the provider states in the note itself on the DOS. Now I'm trying to explain what exactly documentation means. Just because the EHR info. prints out on every encounter note and the provider has to sign it doesn't become documentation.
I'm looking for a better way to explain.

 

[thomas7331]

It sounds like a semantic issue. Everything in the medical record is in fact documentation, but what documentation can be used for purposes of coding what services or what claims is a different question. Perhaps it would help if you could give an example or explain what exactly is the problem that this difference of opinion is causing?

 

[Sarah Ann]

I was offering suggestions for documentation. For instance if they say only pt has a history of this that and the other- nothing else , mentioned on the DOS I suggested even if the pt is here for an arm injury, and the provider only mentions histories without treatment, monitoring etc we can't code a secondary without documentation. Then I was told that the provider signs the note- with all of the lists, medication lists, disease lists, social history lists etc. This is considered "documentation"(to be used for code capture, I should have clarified that) I've personally never considered it.

 

[Sarah Ann]

This is for professional outpatient coding by the way (which are stand alone encounters).

 

[saddie2k]

Are you saying that the info DOES show up but was NOT actively reviewed at that visit? I would say something needs fixed. There should be some sort of time stamp or statement showing that info was reviewed on that date of service. For instance, in our charts the meds and allergies are each indicated as having been reconciled that visit or reviewed on that visit. If not, it either doesn't show up in the final document or says the date it was last reviewed.
If the problems list has conditions that are not documented as being addressed then they don't count towards MDM anyway. They can list 100 diagnoses there but if they only address one then thats all they get credit for.

 

[csperoni]

For pro fee coding, you code what you treat, address, or impacts your care. Even if it is documented as existing and the treatment of it, you do not necessarily code or count it.
I work in gynonc. I do sometimes code diabetes. If the provider wants to do surgery, but the PCP won't clear due to very elevated HgA1c. That impacts our treatment. If the note states "DM II well controlled for 10 years. takes 500mg metformin BID, follows with endo.", I do NOT code DM II since my provider is not treating even though the note specifies the treatment.
I'm assuming someone is incorrectly thinking if you document all the history/problems that exist, it impacts your coding level.
From the AMA 2021 outpatient guidelines:
Problem addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/ surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician r other qualified health care professional reporting the service.

Reviewing a problem or medication list is not the same as addressing the medical condition.