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Wiki Pulling diagnosis from the HPI

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msalvatore

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Croswell, MI
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I need help please, my physicians are pulling dx codes straight from the HPI and not listing the dx in the exam or impression/plan. We just had an BCBS audit and received strikes for not having the dx in the exam or plan.

Example: pt came in for ck up on DM, HPI states this and says pt has no complaints. The plan states no changes at this time, f/u in 3 months. Dr. coded: DM 250.00. The auditers said the dx for DM could not be used.

I need something to take to my Dr.s to convince them they have to have the dx in the exam or plan.
 
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