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Thread: "no change"

  1. #1
    Join Date
    Apr 2007
    Glendale, AZ

    Default "no change"

    AAPC: Back to School
    Is it ok for a Dr to put "no change" on the progress note for the Dx or do they have to actual list the Dx? Thx!

  2. #2
    Join Date
    Apr 2007
    Seacoast- Dover New Hampshire

    Default no change

    No change from what? What is the purpose of the visit? What is the chief complaint?. You would need more information to code this visit.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3


    I agree. The diagnosis, rationale, or impression for the visit should be on the note. Correct me if I'm wrong but I believe that documenting the diagnosis or rationale is included in the documentation guidelines for E/M. Each progress note should stand on it's own. The diagnoses on the bill or claim form should be supported by what is in the progress note.

  4. #4
    Join Date
    Apr 2007
    Glendale, AZ


    Great, that's what I was thinking...the note should stand on it's own. The auditor shouldn't have to search the rest of the chart to figure out the Dx.

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