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Thread: Diagnosis requirement

  1. #1

    Question Diagnosis requirement

    AAPC: Back to School
    One of my behavioral health doctors does not document a diagnosis on his dictation for physchotherapy visits & medication management visitis. I'm new to coding behavioral health so I was wondering is it required to document the diagnosis for each visit or does the diagnosis carry over from the initial interview that was done.

    Also, the same doctor is now seeing patients of another doctor that it no longer with the practice and is just using his diagnoses but not documenting them in his dictation. Is this ok or should their be documentation?

    Teresa D

  2. #2


    Every encounter should be complete on their own. He can't document a DX on intial eval and then every subsequent visit is assumed to be the same. Can't assume. I guess I would view this as lazy documentation

    At a minimum, he should document the DX as "unchanged from April 1, 2009", then you can code from that

    Here is a paste from Medicare/Trailblazer

    Providers should follow these guidelines for medical record documentation when billing for psychiatry and psychology services.
     The medical record should be complete and legible.
     The documentation of each visit should include:
    o The date.
    o The reason for the visit (medically necessary).
    o Appropriate history and physical exam.
    o Review of lab, X-ray data and other technical services, where appropriate.
    o Assessment, clinical impression.
    o Plan for care (including discharge plan, if appropriate).

     Past and present diagnoses should be available to the treating and/or consulting physician.
     The reasons for and results of X-rays, lab tests and other technical services should be documented or included in the medical record.
     Relevant health risk factors should be identified.
     The patient’s progress, including response to treatment, change in treatment, change in diagnosis and patient non-compliance should be documented.
     The written plan for care should include, when appropriate: treatments and medications specifying frequency and dosage; any referrals and consultations (prior to January 1, 2010); patient/family education; and specific instructions for follow-up.
     The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical decision-making.
     All entries to the medical record should be dated and authenticated.
     The CPT/ICD-9-CM codes reported on the health insurance claim form or billing statement should reflect the documentation in the medical record.
    Last edited by sbicknell; 06-07-2010 at 12:06 PM.

  3. #3


    Note has to stand alone, so yes he needs to dictate. If he says " dx same as jan 1, 2009" or whatever, than you need to be sure that you have that note available as well and you would have to sumit both notes if ever requested.

    I advise dictating in each note.

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