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"no change"

kbarron

True Blue
Messages
609
Location
Ossipee, NH
Best answers
0
no change

No change from what? What is the purpose of the visit? What is the chief complaint?. You would need more information to code this visit.
 

member7

Guest
Messages
79
Best answers
0
I agree. The diagnosis, rationale, or impression for the visit should be on the note. Correct me if I'm wrong but I believe that documenting the diagnosis or rationale is included in the documentation guidelines for E/M. Each progress note should stand on it's own. The diagnoses on the bill or claim form should be supported by what is in the progress note.
 

deyoung

Guru
Messages
139
Location
Glendale, AZ
Best answers
0
Great, that's what I was thinking...the note should stand on it's own. The auditor shouldn't have to search the rest of the chart to figure out the Dx. :rolleyes:
 
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