Wiki The NOTE and the EHR

[Sarah Ann]

Urgent care coding-usually people are presenting with a simple problem- sore throat, rash, laceration etc. The EHR- most of the medications and conditions have been addressed by their primary, but because we use the same EHR the info. surrounding the "note" follows the patient from visit to visit.
Here's what I think and have always considered the "note" CC- ROS- Exam- MDM Assessment/plan.
In addition to that I am being told that because the physician signs the "note" which includes-- surrounding the actual note- the problem list the medication list(checked and collected by a nurse ,and the past, family, social history(collected by a nurse)-

Unless there's indication within the note itself I don't feel comfortable adding for instance any of the histories. I was told the other day that because the provider signs off on the note (and the other stuff is in the periphery) it's ok to use it because that means they reviewed everything- use what you need!??!!!!?
"we have to paint a picture of how sick this patient is" What?
"add all conditions that coexist-" Yes, if they address it-- has A- fib is on coumadin- I can see coding it. They are saying that evidence of the disease and treatment should be taken from the list of diseases- if there's a medication on the list that is usually used for one of the diseases on the list, then we can call that "treated", because they review the medications before signing- they're approving everything.
Just trying to get an idea of what others think- I could be going crazy!

 

[thomas7331]

This is always an area of confusion because some employers and payers wish to see only the codes that represent what conditions were involved in the encounter itself (i.e. those that were evaluated or treated, or were a factor in treatment decisions, as documented by the provider) , and others wish to see all conditions that were present and existed for the patient at the time of the encounter - as you've said, to show 'how sick' the patient really is. The latter is usually due to providers or payers who have reimbursement that is tied to risk adjustment and who need to capture a more complete picture of the patient's condition.

Your employer really should give you direction on this. On the one hand, you want to be capturing what data they need, but on the other hand, you don't want to be wasting your time on coding things that they don't need. If you do not get any guidance, then just code according to your understanding of the published guidelines and use those to support your decisions. Unfortunately, a lot of us coders are faced with this situation and don't get this kind of guidance, so we understand what you're feeling!

 

[marklerner]

Thanks for the quick response. I was reviewing these as part of an audit and wasn't sure if the third occipital nerve should be coded 94450