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HELP....documenting in the "proper place"

  1. #1
    Loma Linda- Murrieta Chapter
    Question HELP....documenting in the "proper place"
    Medical Coding Books
    Good morning everyone,

    I am really hoping the members here can help me. We are EMR and I am auditing charts and finding I have some confusion. Of course it is my opinion vs. the physicians, so who better to ask then all of you.

    Ok for example, in the HPI it is noted that patient is here today for Diabetic follow up and say COPD. In the HPI, the physician is putting the information, A1c result, refer to podiatrty/ophthalmology and whatever other info pertaining to the Diabetes. Then they are doing the same for the COPD, pt on meds and stable, will see pulmonary next week. Then when you review the Review of Systems and Physical Exam, nothing is documented under Respiratory or Endocrine/Metabolic, the only documentation in this area may state only the negatives but the disease is not addressed at all. When I have asked the MD's to put the documentation to support their billing in the proper system reviewed, they say they have already documented it in the HPI. Also, when you are in the proper system (respiratory, cardio etc), there is a check box that you can mark "X" that says "see HPI". Is this ok? I have mixed feelings. Initially I thought it was not but the more the physicians say it is documented above in the HPI and it is the same info they would have to re-do, I am starting to question myself as whether or not it really would be ok and pass a CMS audit.....

    My question is, in an audit is that going to pass? OR does is need to be documented in the proper areas? It is truly documented just not in the right place on the electronic record. Now if it was all documented in a "paper chart" it wouldnt be picked apart this way. Love EMR but truly making us over think things.

    The EMR system is NextGen. I appreciate any help and suggestions you have.

    Thank you so much!!!

  2. #2
    Dover Seacoast New Hampshire
    Hi, Debbie. Our providers use NG.

    I'll send you a PM, you can call me.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

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