TTcpc
Guru
I am currently working on a documentation review of a new NP in our Hem/Onc department. I have a case where the patient is 7 y.o. and 29 months post therapy and now in follow-up phase for ALL - per note clinically doing well and no evidence of recurrence. The patient did have a recent episode of cervical lymphadenopathy; however was treated by antibiotics by PCP secondary to enlarged tonsils which at time of this visit with our NP was almost resolved so not deemed a possible recurrence.
Part of me says go with stable chronic illness under the 1st column of the MDM table; however we had a compliance audit from another entity which told us for our ortho patient's who presented for last follow-up visit for a complicated fracture that since it was healed that it would be considered self-limited and no longer an injury. I'm concerned when we undergo another audit by them that the same thing will occur here. Having worked in hospice and palliative care prior - I feel that this would still fall under stable chronic since the patient is still be monitored.
Any advice on how others are managing this in their hem/onc audits would be greatly appreciated!
Part of me says go with stable chronic illness under the 1st column of the MDM table; however we had a compliance audit from another entity which told us for our ortho patient's who presented for last follow-up visit for a complicated fracture that since it was healed that it would be considered self-limited and no longer an injury. I'm concerned when we undergo another audit by them that the same thing will occur here. Having worked in hospice and palliative care prior - I feel that this would still fall under stable chronic since the patient is still be monitored.
Any advice on how others are managing this in their hem/onc audits would be greatly appreciated!