Page 2 of 2 FirstFirst 12
Results 11 to 15 of 15

HELP! Can the Diagnosis be documented anywhere in the note or only the MDM?

  1. #11
    Location
    Columbia, MO
    Posts
    13,122
    Default
    Medical Coding Books
    LOL that s OK I have Doctors that call me Barbara...I hope I did not offend you I was only trying to point out how policies can be contrary to correct coding and detrimental to the patient. I work with a person that only codes from the MDM but can give no defense for her coding other than that is how she has always done it. I have a pocket full of examples where incorrect codes would wind up being delivered coding only from the MDM or A/P.

    Debra A. Mitchell, MSPH, CPC-H

  2. #12
    Location
    Sarasota FL
    Posts
    1,102
    Default diagnoses in the MDM
    Quote Originally Posted by mitchellde View Post
    LOL that s OK I have Doctors that call me Barbara...I hope I did not offend you I was only trying to point out how policies can be contrary to correct coding and detrimental to the patient. I work with a person that only codes from the MDM but can give no defense for her coding other than that is how she has always done it. I have a pocket full of examples where incorrect codes would wind up being delivered coding only from the MDM or A/P.
    Absolutely no offence taken and I agree with you. As I said, this is a client-only policy for the work I do. I have no say in the matter other than our team being able to convey our dislike of the policy to the client.

  3. #13
    Default
    Shouldn't the diagnoses included in the A/P be supported by what is documented in the history and exam?? You shouldn't include diagnoses that are not supported anywhere else in the note. There should be documentation as to why they included the diagnoses in the assessment.
    Thank you,

    Abby Ronco-Hopkins, CPC, CPMA
    Family Practice Center, PC
    Medical Auditor

  4. #14
    Default
    It is often very helpful to have a structured note with "History/Subjective", "Physical Examination/Objective" and "Medical Decision Making/Assessment and Plan - usual space for Diagnoses" separated out. However, I have not seen any direct guidelines from CMS which suggest providers must split up their note.

    I have audited providers who have documented in one large text blurb, and have still been able to pick out the History, Exam and MDM. As long as an auditor you don't "double dip", then you should be good to go.
    "Without hard work, nothing grows but weeds"
    -Gordon B. Hinckley

  5. #15
    Location
    SHREVEPORT/BOSSIER CITY
    Posts
    38
    Default
    Every practice is different. For some physicians, it is best to require every note element go in its intended place.

    Example, in my practice, we are all rushed and busy 24/7. The physicians are not strong with documentation, and often sign off on notes that are inconsistent, containing extraneous dx ( they will report a dx on the superbill that is not in the note, usually the dx was reported as their initial impression and a final dx was confirmed in the note, but not deleted from the superbill) lacking, and even completely missing in some cases. They indicate services that were not carried out, or provide no details for them such as our current focus on EKGs and ear lavages.

    Obviously, that pattern cannot be trusted, and my physicians are queried often. They do not like it, but their documentation is improving. Also it is hardly their fault, our RHC is busiest in our region of the state. At the end of the day, always go for the best possible results to enhance patient care.

Page 2 of 2 FirstFirst 12

Similar Threads

  1. Sequence of Diagnosis Code(s) -doctor documented in his chart
    By C Clark CPC CEDC in forum Diagnosis Coding
    Replies: 2
    Last Post: 03-13-2014, 01:59 PM
  2. Documented time within office visit note
    By LanaW in forum Auditing General Discussion
    Replies: 2
    Last Post: 09-11-2012, 10:26 AM
  3. HELP!!documented in note but not listed in bill
    By aimie in forum Auditing General Discussion
    Replies: 4
    Last Post: 10-28-2011, 03:05 PM
  4. Time documented in Prolonged Service note.
    By rtkalvin in forum Billing/Reimbursement
    Replies: 4
    Last Post: 10-13-2011, 10:14 AM
  5. How long before a note must be documented
    By ScottC314 in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 01-02-2008, 11:32 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.