# EHR problem list



## becka95 (Aug 5, 2014)

I understand that the "problem list" is a tool that is used for meaningful use. However, I am running into issues with information that was provided to my company which was passed down to physicians that the problem list is the list of diagnosis that are being used for that encounter. I work for a company that handle multiple wound care centers and the diagnosis can change from one visit to another but not always. I have tried to explain to the staff and trainers that each visit stands alone and that the documentation needs to support the diagnosis and treatment rendered during that visit. 

 the EHR company has told physicians that the problem list is supporting documentation and it flows to the electronic superbill. As a coder, my responsibility is to review the documentation, query the doctors for clarifications and code based on the documentation provided. I am constantly removing their diagnosis that flowed over from the problem list and adding the codes that are appropriate for that encounter. Usually the diagnosis that the physician has on the problem list is not documented at all in the chart not even in the medical history. Other times, the documentation supports a more specific code than the one in the problem list. 

 I do NOT change the codes in the problem list due to company policy. I only change the diagnosis on the superbill since this is not part of the chart. 

 Does anyone have a reference stating that the problem list is considered supporting documentation for coding? My understanding is that the problem list is a tool for the staff and other care provider to exchange key clinical information. It also lists specific conditions for quality improvement. But I cannot find anything that states it is used for coding. 

 I have tried to send a problem list change list and sent charts back because the problem list diagnosis is not documented. This is extremely time consuming for both me and the physicians. The physician are not willing to update the problem list or documentation to support the diagnosis in the problem list. 

 I have no idea where to go to find this information. Obviously the EHR company is not the place to go because they are the ones who told the Dr's that it is supporting documentation. Please help!


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## cluke (Aug 5, 2014)

I found this on the SCAN Health Plan- HCC University Web-site:

Although the term "problem list" is commonly used with regard to ambulatory medical record documentation, a universal definition does not exist. The problem list is generally used by a coder to gain an overall clinical picture of a patients condition(s). Problem lists are usually supported by other medical record documentation such as SOAP Notes (subjective, objective, assessment, plan), progress notes, consultation notes, and diagnostic reports.?

For CMS risk adjustment data validation purposes, an acceptable problem list must be comprehensive and show evaluation and treatment for each condition that related to an ICD-9 code on the date of service and must be signed and dated by the physician or physician extender.


I found this on the Excellus Medicare Advantage Risk Adjustment Program Web- site:

It is important for the physician?s office to fully code each encounter; the claim should report the ICD-CM code of every diagnosis that was addressed, and should only report codes of diagnoses that were actively addressed.
Contributory (co-morbid) conditions should be reported if they impact the care and are therefore addressed at the visit, but not if the condition is inactive or immaterial. It should be obvious from the medical record entry associated with the claim that all reported diagnoses were addressed and that all diagnoses that were addressed were reported.


Medical Record Documentation
-Documentation should be clear, concise, consistent, complete and legible.
-Document coexisting conditions at least annually.
-Use standard abbreviations.
-Utilize problem lists (ensuring they are comprehensive, show evaluation and treatment for each condition relating to an ICD-CM code on the date of service, and are signed and dated by the physician or physician extender).
-Identify patient and date on each page of the record.
-Authenticate the record with signature and credentials.

I hope this helps.


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## susanl3e (Aug 6, 2014)

I am an EHR trainer and we also train our clients on Meaningful Use. The Problem List is utilized for Current and Active Long Term Illnesses and/or Chronic Diagnosis etc. For example, Diabetes, Hyptertension or Asthma is considered a Chronic diagnosis and/or long term diagnosis. 
The Problem List shouldn't be utilized for encounter diagnosis codes because these codes are not considered a long term problem and/or chronic diagnosis.

I've seen some of our providers input Anxiety, Depression, ADHD, Suicidal, Osteoporosis and Degenerative diseases as a Problem List, which is fine as well.

If a patient was seen for UTI or URI, these codes are not considered a Problem List code. If you need more information, please feel free to ask me. Hope this helped.

Also, I am not sure which EHR company you guys are using, but to me that doesn't sound accurate what they are telling the providers. The patients Problem List is NOT an electronic superbill, this is exactly like a patients paper Problem List on their charts. I used to work for two different providers, an internal medicine and an orthopedic surgeon and they both used the Problem List the same way we train our clients to input their chronic/long term diagnosis. I would advise the providers not to always listen to EHR companies when it comes to these kind of things. The Problem List whether it is electronic or paper, should always remain the same as how the provider utilized it. You don't need supporting documentation for the Problem List, if the patient has diabetes, the provider should already have documentation that the patient is diabetic whether by another providers diagnosis or the providers own.


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## lkoehler (Aug 21, 2014)

*Problem List Question*

With Stage 2 Meaningful Use, the nurses are allowed to go into the CPOE and enter lab orders etc.  Are they allowed to enter problems in the problem list to complete the lab order process or does the provider have to enter the problems?  Thanks.


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## susanl3e (Sep 16, 2014)

lkoehler said:


> With Stage 2 Meaningful Use, the nurses are allowed to go into the CPOE and enter lab orders etc.  Are they allowed to enter problems in the problem list to complete the lab order process or does the provider have to enter the problems?  Thanks.



It depends on how the EHR system is capturing the data. you might want to check with your EHR vendor. The EHR system I am supporting allows the nurse to enter the information as long as the provider views this information during the encounter.


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## ChristieH (Sep 25, 2014)

slee_iit said:


> It depends on how the EHR system is capturing the data. you might want to check with your EHR vendor. The EHR system I am supporting allows the nurse to enter the information as long as the provider views this information during the encounter.



Susan, we just started posting charges on ECW (our new EHR/EMR provider) this week. I was told today that I could add the DX codes to the problem list (I post charges for the pt's we are seeing in the hospital) so that when I go back to post additional charges, which will very likely be the same DX codes, it will be easy for me to copy from the problem list.  But it sounds like you are saying only a doctor and maybe a nurse should be putting codes on that problem list. I did notice the system logged my name as the person who put that DX code on the list. Since you are a trainer, do you think it is incorrect info that I got about it being okay for me to put DX codes on the PL?  Your I out is appreciated.   Christie


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