A diagnosis is "counted" if it was evaluated and managed during the encounter. Documentation guidelines state, "It may be explicitly stated or implied in documented decisions regarding management Plans and/or further evaluation", for instance, ordering a test implies further evaluation. However, documentation should be explicit in describing treatment initiation and changes, referrals, consults “to whom or where the referral or consultation is made or from whom the advice is requested”.
Nothing beats explicit though, huh? – Medical providers should be strongly encouraged to document in this manner. It doesn’t have to be voluminous, only substance.
Examples of explicit, but concise Plan documentation might be, “continue current treatment” (treatment must be evident to reviewer); “encouraged compliance”; “continue to monitor”; “pt to keep home log and report (call/or next visit)”; “continue f/u with physician(s) [other medical providers participating in care]”; and similar such recordings. Additionally, a Plan also includes recommended follow-up and/or advice to call if not improving, worsening, report side effects, return prn, keep previously scheduled appointment, etc.
Unless quoting the guidelines and the examples offered answered your question, it would be helpful to know clinical circumstances, and what exactly is documented in your example, in which there is no noted Plan.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join