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NANASIA

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HELP I NEED YOUR EXPERT ADVICE Diagnosis coding not supported

Hi,

I am trying to find the definition for "treating contions or diagnosis". My doctors are billing 10-15 diagnosis codes for every patient. The doctors are not treatIng the condItions just adding the patient's medical history. Does anyone know written rules when selecting DX codes it MUST be supported by the note? The doctors are in for a serious audit. Please advise. Thanks
 
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To be coded, the diagnosis should be addressed in some way. There are more than one way to address a diagnosis.

HIV, being followed by Infectious Disease Specialist.
Hyperlipidemia, uncontrolled. Patient refuses medication.
COPD, stop smoking strongly advised.
Atrial Fibrillation, patient is on Coumadin. Continue to monitor PT/INR monthly.
Hypertension, stable. On atenolol.
Hypothyroidism, severe noncompliance with medical treatment. Patient, again, refuses any medication.
etc etc etc
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What they don't want to see is a laundry list of DXs in a note showing absolutely no medical necessity, in regards to the patient visit, in the first place.

For example:
Patient comes in today for follow up. Feels great.

HEENT: Normal
Heart: RRR
Lungs: Clear to auscultation
Abd: Soft, nontender, no organomegaly
Ext: + pulses, no edema


HIV
Hyperlipidemia
COPD
Atrial Fibrillation
Hypertension
Hypothyroidism

PLAN: See patient back in 4 weeks.

:Four weeks later:

Patient comes in today for follow up. Feels great.

HEENT: Normal
Heart: RRR
Lungs: Clear to auscultation
Abd: Soft, nontender, no organomegaly
Ext: + pulses, no edema


HIV
Hyperlipidemia
COPD
Atrial Fibrillation
Hypertension
Hypothyroidism

PLAN: See patient back in 4 weeks.

:Four weeks later:

Patient comes in today for follow up. Feels great.

HEENT: Normal
Heart: RRR
Lungs: Clear to auscultation
Abd: Soft, nontender, no organomegaly
Ext: + pulses, no edema


HIV
Hyperlipidemia
COPD
Atrial Fibrillation
Hypertension
Hypothyroidism

PLAN: See patient back in 4 weeks.
_________________________________________

You get the point. May as well be carbon copies! It happens all the time. If the doctor is not managing the patient's care in some way, whether it be reviewing specialist notes, tweaking meds, counseling patient on risk modification, SOMETHING, the doctor should not expect any sort of compensation for the visit. Documentation is EVERYTHING. If it's not documented, it wasn't done. Insurance carriers want to know that something was done and that they are not paying the docs for nothing.
 
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Hi thank you very helpful. I need something from Medicare or aapc or ama that gives the meaning on what is treating a diagnosis code for example counseling, writing a prescription, ordering tests and etc. Compared to what is not considered treating a condition and is not billable. The doctors need to know the detailed difference. Please someone help. Thanks
 
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