Wiki Number & Complexity of problems addressed question

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How are you handling if if you have a diagnosis that doesn't really fit in any of the categories they give? Like we have patient's with Elevated PSA, not noted as stable, nothing being done for it, or bph noted as having good response to medication, well the PSA doesn't really fit in chronic stable or acute uncomplicated and the bph doesn't really fit in chronic stable or chronic with exacerbation.... Or conditions that don't fit in any of the options, like ED, hasn't had it for a year so it can't be chronic, its not acute, and from the AAPC workshop for training physicians it wouldn't really be considered self limited or minor as ED wouldn't resolve on its own. Its hard enough with diagnoses like this on established patient's but even more difficult on new patients because if they're new we most likely won't know if the condition they're seeing us for is chronic and if we can't fit in chronic and it doesn't fit in acute or self limited/minor, where do we put it?

We have to have audits with our providers and though some notes are quite easy to figure out and tell them definitively why their visit wasn't a 4 but a 3 some I'm having a very hard time with solely due to not being sure where the diagnosis or diagnoses fall, in level 3 or level 4 and if I can't say definitively I know they'll fight me on it, especially if I down coded them from a 4 to a 3.

Any suggestions?

Thank you
 
I fall back to how is it being addressed as the AMA guidelines pointed out on page 3. Also, the notes must be specific and clear as to what transpired on that visit date. One of the webinars I attended said that it needs to be clear to non-clinical staff and if it isn't clearly stated and supported by notes then it can't be counted. I don't know if this is at all helpful or not but hope so!
 
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