My response to him is that the exam section is for documentation of his findings, while the assessment...well it's just that, his conclusion of the patients problems. If from his exam he has findings that a certain chronic condition is unstable, or better, or whatever, that should be reflected in his assessment. As auditors, we cannot assume anything. If the assessment said "DM" only, but the exam said the patient had nerve pain in his hands and feet...should we assume the patient hads dm with neuro manifestations and code it as such? No.
While we can get a feel of how sick the patient is by the documentation, the only way to support the MDM is with a clear picture of what is going on with the dx's.
I am with you that there should be some sort of status with the assessment.
The 95 documentation guidelines say this:
"For a presenting problem with an established diagnosis the record
should reflect whether the problem is: a) improved, well controlled,
resolving or resolved; or, b) inadequately controlled, worsening, or
failing to change as expected."
While he may argue the exam notes will "reflect" this, I would again make the point that he is leaving it up to the auditor to make a conclusion.
- 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