Wiki Auditing Opinion Needed

[m.matos@chcfl.com]

As a coder i can not diagonsis from past documenation but can the provider? He is pulling diagnosis from past lab results and past progress notes but in the current days progress note there is no documenation to support. He feels that as long as the chart as a whole can support his diagnosis and his current days progress note doesnt need to.

Are there any resources out there I can use with more details on documenation and auditing?

If we were to get audited would they search through the chart as a whole or reviewed only the current progress note for the supporting documentation?

Thanks

 

[Daniel Rowden]

Everything must be supported each visit in the current progress note no matter who is coding.

It would be the current progress note for the specific day if you were audited.

 

[mitchellde]

It does not matter where he pulls the dx from, but does he evaluate it, treat, or does it impact part of the current problem or treatment. He must make it relevant, just listing a diagnosis without having any relevance for it in the exam or treatment, means that diagnosis does not get coded for the encounter. If the patient is there for say foot pain and the provider lists say lung cancer as a diagnosis, but does not include this in any part of the discussion of the foot pain or treatment, the lung cancer will not be coded.