# Documentation being audited



## lillianivy (Feb 19, 2014)

I need help!!!  My doctors need concrete guidelines informing them what documentation is audited.  Basically, they are disputing that if a dx is on a lab/rad/other note, but not on that DOS documentation that since it is somewhere else in the chart it's fine.  My impression is that only that DOS medical note is what is audited and if it is not documented on that one note then you can't use it.  Also, that the results from labs/rad reports reviewed for that visit must be noted on the medical note. Can anyone point me to the specific guidelines regarding this?  Or informing me of what documentation is audited.  Thanks so much. 

Lydia


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## dtlandry67 (Feb 20, 2014)

If a diagnosis is billed for a DOS then the documentation must show a correlation for the Dx from HPI, Exam and MDM.  It is imperative that the documentation demonstrates that all dx billed were being evaluated and treated at that episode of care. All dx billed should have a plan also.  If  dx codes are billed but not correlated throughout the note or have a plan documented then they can be discounted as only an active problem list.  This all must be in the note for the particular episode of care, not somewhere else in the chart.  

Hope that helps!

Dawn


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## lillianivy (Feb 20, 2014)

Thank you, Dawn.  I agree with your statement 100%.  But I need this information in writing as the guidelines.  Is there a specific article, link, or auditing guideline report with that precise information?  

Lydia


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## Quaker (Feb 21, 2014)

Lydia, diagnosis coding rules are in the front of the ICD-9-CM book. 
Hope this helps.

Arlene


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## Stacixu04 (Feb 24, 2014)

*Coding Clinic*

Here is a coding clinic that may help:

Assigning codes using prior encounters - Coding Clinic, Third Quarter 2013 Pages: 27-28 Effective with discharges: September 10, 2013

Documentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter. Conditions documented on previous encounters may not be clinically relevant on the current encounter. The physician is responsible for diagnosing and documenting all relevant conditions. A patient's historical problem list is not necessarily the same for every encounter/visit. It is the physician's responsibility to determine the diagnoses applicable to the current encounter and document in the patient's record. When reporting recurring conditions and the recurring condition is still valid for the outpatient encounter or inpatient admission, the recurring condition should be documented in the medical record with each encounter/admission. However, if the condition is not documented in the current health record, it would be inappropriate to go back to previous encounters to retrieve a diagnosis without physician confirmation.

This is an area where coders and/or department managers may need to educate physicians and/or practice managers on the need to include complete diagnoses when outpatient services are ordered and to continue to document chronic or longstanding conditions on each admission/encounter record.


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## ditsche (Jul 17, 2014)

We use Novitas Solutions as our point of reference for E/M documentation requirements. 

www.novitas-solutions.com

There is an E/M scoresheet that is an excellent auditing tool to make sure the documentation supports a level of service. There is also an E/M FAQ document that answers many of the physicians general questions.

I hope this is helpful.

Kelly


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