insufficient documentation for E/M?

tag60

Guru
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I have a provider who often gives a diagnosis that is not addressed in his documentation. He will order labs or refill meds based on the diagnosis, but again, he doesn't explicitly state the chief complaint is for the diagnosis he has given, and he does not provide any further information on the diagnosis (status, update). Please read below and advise on whether you would feel comfortable coding an E/M visit:

CC: Lab results.
OBJECTIVE: General: NAD.
HEENT: Unremarkable.
Neck: Supple.
Heart: RRR
Pulm: Clear.
A/P: Labs WNL.
1. Anxiety disorder. Refer to Mental Health.
2. Bereavement. Improving.
3. Virilization-androgenital syndrome. Labs negative.

Provider has done an exam and placed orders...but is documentation sufficient to support his diagnoses and code an E/M visit? (That is, where did those DX come from? Not addressed in CC/subjective. No history given.)

Thanks in advance!
 

mitchellde

True Blue
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13,537
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Columbia, MO
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The diagnosis needs to be addressed in the exam note to show why the examination is important or relevant to the problem.
 
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