dleggett2495
New
Hi all,
My team and I are in a new department focusing on Risk Adjustment/HCC Auditing and we have come across a couple of providers using the following description in their assessment/plan as opposed to actually listing the condition and their plan of action. It goes as follows:
"This established patient has 3 or more chronic/active conditions, those addressed or pertinent to today's visit are listed below in the "Assessment and Plan". The status of each of those chronic conditions listed is assessed by me personally and is reported by the patient to be stable unless otherwise noted in today's report.
This Progress note is a best effort summary of the salient aspects of this patient's encounter today. Additional items and issues may have been addressed though not documented due to the lengthy process of medical documentation and the intent to efficiently record the most significant."
We are questioning the compliance and wondering if this is actually okay for the docs to use, instead of being more specific in their notes. Their diagnosis codes are on the claim and visit in the EMR. Just no description in the assessment/plan except for that which I typed word for word above.
Any help is greatly appreciated.
My team and I are in a new department focusing on Risk Adjustment/HCC Auditing and we have come across a couple of providers using the following description in their assessment/plan as opposed to actually listing the condition and their plan of action. It goes as follows:
"This established patient has 3 or more chronic/active conditions, those addressed or pertinent to today's visit are listed below in the "Assessment and Plan". The status of each of those chronic conditions listed is assessed by me personally and is reported by the patient to be stable unless otherwise noted in today's report.
This Progress note is a best effort summary of the salient aspects of this patient's encounter today. Additional items and issues may have been addressed though not documented due to the lengthy process of medical documentation and the intent to efficiently record the most significant."
We are questioning the compliance and wondering if this is actually okay for the docs to use, instead of being more specific in their notes. Their diagnosis codes are on the claim and visit in the EMR. Just no description in the assessment/plan except for that which I typed word for word above.
Any help is greatly appreciated.