# HELP!  Can the Diagnosis be documented anywhere in the note or only the MDM?



## purplescarf23

Good morning, I've always been instructed (for over 12 years) that the diagnosis MUST be documented in the MDM portion of a chart note.  Even the guidelines cover this in that section and don't address it in other sections of the E/M.  However I have a few Vascular providers pushing back that the diagnosis can be taken from anywhere in the note.  I don't agree with this. However does anyone have something stating one way or the other?  I've googled the web more times than I can count and come up with nothing each time.  Any help is greatly appreciated.

Thank you
Kelsey, CPC, CEMC


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## Chelle-Lynn

While it is recommended for the provider to document the assessment and medical decision making in the section of the records specifically identified for this purpose...If the documentation clear shows that the provider is noting a diagnosis along with the assessment and treatment, then it would not matter where the physician listed their diagnosis/assessment as long as they signed the record in attestation to their exam and review.

For example if during the course of the musculoskeletal exam the physician decides to document that the patient has an ankle sprain and is recommending rest and ice, that would be clear enough to allow for the diagnosis of the ankle sprain.


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## purplescarf23

Chelle-Lynn said:


> While it is recommended for the provider to document the assessment and medical decision making in the section of the records specifically identified for this purpose...If the documentation clear shows that the provider is noting a diagnosis along with the assessment and treatment, then it would not matter where the physician listed their diagnosis/assessment as long as they signed the record in attestation to their exam and review.
> 
> For example if during the course of the musculoskeletal exam the physician decides to document that the patient has an ankle sprain and is recommending rest and ice, that would be clear enough to allow for the diagnosis of the ankle sprain.



Thank you for your reply.  So if this is the case then each section/components of the E/M level does not need to stand on its own?  Wouldn't that sort of be double dipping to make each section 'complete'?  Do you have something written that it would be OK to allow this?  My place of employment is really trying to find something written by a reputable establishment for one way or the other on this matter.  Thanks again for your reply!  Appreciate it!


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## Chelle-Lynn

CMS provides the following guidelines in regards to documentation for E&M visits.  However, they do not specify what order they are required to be listed in the medical records or whether they are required to be under certain headers such as SOAP or History/Exam/MDM.  They require only that the data support the billing of the CPT, HCPCS, and DX codes.   This is a frustrating grey area for us.

In regards to "double dipping" as only the data abstracted from the records can only be "counted" once regardless of the location it is documented.



https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf


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## TThivierge

*MDM should list diagnosis code*



purplescarf23 said:


> Good morning, I've always been instructed (for over 12 years) that the diagnosis MUST be documented in the MDM portion of a chart note.  Even the guidelines cover this in that section and don't address it in other sections of the E/M.  However I have a few Vascular providers pushing back that the diagnosis can be taken from anywhere in the note.  I don't agree with this. However does anyone have something stating one way or the other?  I've googled the web more times than I can count and come up with nothing each time.  Any help is greatly appreciated.
> 
> Thank you
> Kelsey, CPC, CEMC




Hi Kelsey

You are correct!

Lady T


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## mitchellde

I look at the note as one entire thing and not separate parts so in my mind I agree with the providers the dx can come from anywhere in the note.  However by not having medical decision making to coincide with it the visit level may not be as high as they want.  but the medical necessity can be found within the context of the note. 
so here is a question what if you have something in the MDM that is not supported in the exam.. For instance I have a note where the MDM indicates a vaginal discharge and a treatment for it.  however in the examination it states all is normal and no discharge.. there is no complaint from the patient regarding any discharge or itching or any discomfort. The visit was for completely other issues.  The question then is because it is in the MDM do you code it?
I do not.  Although I do query the provider.


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## twizzle

*Diagnoses and MDM*



purplescarf23 said:


> Good morning, I've always been instructed (for over 12 years) that the diagnosis MUST be documented in the MDM portion of a chart note.  Even the guidelines cover this in that section and don't address it in other sections of the E/M.  However I have a few Vascular providers pushing back that the diagnosis can be taken from anywhere in the note.  I don't agree with this. However does anyone have something stating one way or the other?  I've googled the web more times than I can count and come up with nothing each time.  Any help is greatly appreciated.
> 
> Thank you
> Kelsey, CPC, CEMC



The client I currently audit will only allow diagnoses documented in the A/P and that have an associated plan of care. They cannot be taken from anywhere else in the note. This can cause problems because they may document pain and tenderness in the LLQ of the abdomen in the exam section or the HPI, but the A/P says abdominal pain. We have to go with the unspecified abdominal pain R10.9 which is frustrating knowing there is a more specific code available.

Their only exceptions are BMI which can be taken from the exam when dealing with obesity diagnoses, and long term use of insulin which can be taken from the meds or elsewhere in the documentation when coding DM. It would not be coded if the patient was taking insulin for any condition other than DM (which can happen).

There are no hard and fast rules as the original poster has stated, and the internet oftentimes is not much help.


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## mitchellde

So Twizzle.. In the case I cited where the A/P indicates vaginal discharge with meds order you would code that even though the note dictates in specific language no discharge and this was not the complaint by the patient. In fact the only place in the entire note where vaginal discharge is mentioned is the A/P.  see I think that is just not OK..  I think the whole note goes together or it all falls apart.  I have an auditor that did the same as you and would give me points off for diagnosis and each time I would appeal and win.  I finally convince them when I had one where the A/P indicated the patient was a smoker and I did not code for tobacco use. I pointed out in the note where it stated patient smokes cannabis and no where in the note did it ever indicate tobacco.  Insurance takes a bad view of patients that smoke tobacco so to use that code would be a disservice to the patient.


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## twizzle

*Diagnosis codes and MDM*



mitchellde said:


> So Twizzle.. In the case I cited where the A/P indicates vaginal discharge with meds order you would code that even though the note dictates in specific language no discharge and this was not the complaint by the patient. In fact the only place in the entire note where vaginal discharge is mentioned is the A/P.  see I think that is just not OK..  I think the whole note goes together or it all falls apart.  I have an auditor that did the same as you and would give me points off for diagnosis and each time I would appeal and win.  I finally convince them when I had one where the A/P indicated the patient was a smoker and I did not code for tobacco use. I pointed out in the note where it stated patient smokes cannabis and no where in the note did it ever indicate tobacco.  Insurance takes a bad view of patients that smoke tobacco so to use that code would be a disservice to the patient.



Good morning Deborah.....I only cited this particular example because my client (not me, not the company who employs me) have their own rules......some make sense and some do not. None of the auditors in our team or our manager like some of their rules but we have to run with them. I have never audited this way before where the diagnosis has to be in the A/P and nowhere else. Because the client has their own educators it is our role to point out discrepancies when performing an audit....the onus is then on the educators to educate and query any inconsistencies.

In your example I really would want to query the provider because there are inconsistencies. I've seen providers who have mixed notes up resulting in a piece of one patient's care ending up in another patient's notes. I probably wouldn't code the vaginal discharge in your example because it was not a complaint and the exam was normal for that problem but without seeing the whole note I can't be sure.


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## twizzle

*Diagnosis in the MDM*

Debra....I apologize for spelling your name incorrectly.


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## mitchellde

LOL that s OK I have Doctors that call me Barbara...I hope I did not offend you I was only trying to point out how policies can be contrary to correct coding and detrimental to the patient.  I work with a person that only codes from the MDM but can give no defense for her coding other than that is how she has always done it.  I have a pocket full of examples where incorrect codes would wind up being delivered coding only from the MDM or A/P.


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## twizzle

*diagnoses in the MDM*



mitchellde said:


> LOL that s OK I have Doctors that call me Barbara...I hope I did not offend you I was only trying to point out how policies can be contrary to correct coding and detrimental to the patient.  I work with a person that only codes from the MDM but can give no defense for her coding other than that is how she has always done it.  I have a pocket full of examples where incorrect codes would wind up being delivered coding only from the MDM or A/P.



Absolutely no offence taken and I agree with you. As I said, this is a client-only policy for the work I do. I have no say in the matter other than our team being able to convey our dislike of the policy to the client.


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## ivygirl18@hotmail.com

Shouldn't the diagnoses included in the A/P be supported by what is documented in the history and exam?? You shouldn't include diagnoses that are not supported anywhere else in the note. There should be documentation as to why they included the diagnoses in the assessment.


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## Pathos

It is often very helpful to have a structured note with "History/Subjective", "Physical Examination/Objective" and "Medical Decision Making/Assessment and Plan - usual space for Diagnoses" separated out. However, I have not seen any direct guidelines from CMS which suggest providers must split up their note. 

I have audited providers who have documented in one large text blurb, and have still been able to pick out the History, Exam and MDM. As long as an auditor you don't "double dip", then you should be good to go.


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## Agilbert3

Every practice is different. For some physicians, it is best to require every note element go in its intended place.

     Example, in my practice, we are all rushed and busy 24/7. The physicians are not strong with documentation, and often sign off on notes that are inconsistent, containing extraneous dx ( they will report a dx on the superbill that is not in the note, usually the dx was reported as their initial impression and a final dx was confirmed in the note, but not deleted from the superbill) lacking, and even  completely missing in some cases. They indicate services that were not carried out, or provide no details for them such as our current focus on EKGs and ear lavages. 

     Obviously, that pattern cannot be trusted, and my physicians are queried often. They do not like it, but their documentation is improving. Also it is hardly their fault, our RHC is busiest in our region of the state.  At the end of the day, always go for the best possible results to enhance patient care.


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