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Thread: establish problem worsening

  1. #1

    Default establish problem worsening

    AAPC: Back to School
    Does the provider have to state that the pts condition has worsened in his chart notes? Alot of the notes that I'm reading say, pt presented with back pain. It is described as aching. The symptom is ongoing, in additon. she presented with pain scale 5/10. Vicodin was prescribed for pain.

    I'm thinking this is an established pt stable.

  2. #2
    Join Date
    Apr 2007
    York, Pa


    So are the meds being prescribed at this present visit? And it sounds to me like this could be a f/u appt to the same issue? Am I correct?

    I'd actually be more comfy seeing the actual note- sanitized of course!
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
    Join Date
    Apr 2007


    What you've written looks stable to me. In our audits, we explain to providers that the note has to lead us to the fact that its worsening.... if stated previous visit patient was at 2/10 for severity and now 5/10 then it can be construed that its worsening. Its all in the info they provide, unfortunately most providers dont get all of it down in their notes.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  4. #4


    Ok I have the idea now, thanks to both of you.

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