AAPC - Back to school
Results 1 to 3 of 3

Thread: Auditing EHR Medical Decision Making containing only DX Codes

  1. #1
    Join Date
    Apr 2007
    Seattle First Hill Washington 20608

    Default Auditing EHR Medical Decision Making containing only DX Codes

    AAPC: Back to School
    We have a new EHR and in-order to make everything go smoothly the progress note must have actual ICD-9 codes in the documentation, in the EHR.

    I review notes, and provide education feedback to the doc’s. However, I’m not sure how to proceed with this since I’ve never come across it before. The assessment and Plan in the providers note(s) has ICD-9 codes as their assessment and plan. So, their note will have HPI, ROS, Exam than ICD-9 codes for the assessment and plan.

    This is their decision making process and they have determined the patient has the problem. However, I am used to reading an assessment and plan to determine the level of service and the diagnosis of the patient.

    Is it appropriate to have a progress note which only has ICD-9 codes as the assessment and plan?

    Any feedback will be helpful.

  2. #2

    Default Assessment ICD9 codes

    Does anyone have an answer to this question?????

  3. #3
    Join Date
    Apr 2007


    We currently code from our EHR and had the problem of the provider putting the problem list as their assessment and plan (list ICD9 codes). Our coding team came up with the policy that we would only count those diagnoses if they had a statement that showed MDM. Stable, improved, change Rx etc. There must be some editing by providers to support that they are either evaluating or managing the problems.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

Similar Threads

  1. Medical Decision Making
    By midnightsun1369 in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 03-27-2015, 12:17 PM
  2. Auditing Medical Decision Making
    By adri3421 in forum Auditing General Discussion
    Replies: 48
    Last Post: 07-31-2014, 03:01 PM
  3. dx codes affecting medical decision making
    By abranch13 in forum Diagnosis Coding
    Replies: 0
    Last Post: 11-08-2012, 11:06 AM
  4. Medical Decision Making
    By Lassal423 in forum E/M
    Replies: 3
    Last Post: 09-13-2012, 03:28 AM

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?


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.