pedscoder21
Guru
Question! 
Scenario: patient presents for evaluation and management of cough and runny nose. Patient is diagnosed with common cold. Physician's assessment and plan:
Common cold
Diabetes
Seizure disorder
The physician codes all of the above on the encounter.
There is nothing in the documentation that the diabetes and seizure disorder were discussed during the examination. The only place in the EHR that these diagnoses are recorded is the patient's "problem list". Does this mean that these codes shouldn't be reported?
I have always been under the impression that the documentation needs to support reporting each diagnosis (of course), such as reporting that the patient's medications for diabetes were reviewed and won't affect the current treatment of the cold...
Is a chronic condition listed in the EHR's problem list enough to support reporting it?
Thank you!
Scenario: patient presents for evaluation and management of cough and runny nose. Patient is diagnosed with common cold. Physician's assessment and plan:
Common cold
Diabetes
Seizure disorder
The physician codes all of the above on the encounter.
There is nothing in the documentation that the diabetes and seizure disorder were discussed during the examination. The only place in the EHR that these diagnoses are recorded is the patient's "problem list". Does this mean that these codes shouldn't be reported?
I have always been under the impression that the documentation needs to support reporting each diagnosis (of course), such as reporting that the patient's medications for diabetes were reviewed and won't affect the current treatment of the cold...
Is a chronic condition listed in the EHR's problem list enough to support reporting it?
Thank you!
