Wiki Assessment and Plan

[DeniMCharlotte]

I have a few providers who consistently leave their assessment and plan out of their documentation. What is a good way to address this with them? I've provided them with several examples where they list the condition but there is nothing documented beside it and the HPI does not mention them, and my inclination is to leave those off of the claim. However, I've run into a few scenarios where ALL conditions listed do not have an assessment and plan and I've become frustrated and inundated with these encounters. I looked on CMS and printed information regarding the issue of insufficient documentation. I'm just curious if anyone else has encountered this issue or has a better way to deal with it. This is for a Family Medicine / Internal Medicine practice. Any help is appreciated. I've been coding for two years and I've never run into this with other providers.

 

[slivingston]

Can I ask if there is no Assessment and Plan how are these visits being coded? You would need to know how a condition is being managed and the plan going forward to accurately assign a CPT code.