Wiki Diagnosis help on chronic conditions

[adweaver]

I am auditing a patients chart and am coming across a documentation discrepancy. The doctor documents in the CC "Patient presents for hypertension, hyperlipidemia and diabetes. patient continues to follow up with providers for his ca prostate and bladder. c/o stinging, itching both feet" but then in the HPI only discusses the diabetes. In the MDM of the note he blows in every dx mentioned in the HPI (Diabetes, hypertension, hyperlipidemia, anemia, carcinoma prostate, carcinoma bladder). I believe only the diabetes is supported based on this documentation. Can you use a dx if it isn't mentioned the status of it? Under the dx of diabetes there were labs ordered and follow-up. The other dx's listed only say "Patient voiced understanding of the instructions." Any suggestions????

 

[rthames052006]

I am auditing a patients chart and am coming across a documentation discrepancy. The doctor documents in the CC "Patient presents for hypertension, hyperlipidemia and diabetes. patient continues to follow up with providers for his ca prostate and bladder. c/o stinging, itching both feet" but then in the HPI only discusses the diabetes. In the MDM of the note he blows in every dx mentioned in the HPI (Diabetes, hypertension, hyperlipidemia, anemia, carcinoma prostate, carcinoma bladder). I believe only the diabetes is supported based on this documentation. Can you use a dx if it isn't mentioned the status of it? Under the dx of diabetes there were labs ordered and follow-up. The other dx's listed only say "Patient voiced understanding of the instructions." Any suggestions????

From the gist of the note you've described the pt was seeing this provider for f/u of HTN, lipids and DM. Did the provider happen to give the status of these conditions in the A/P.

In the DG for 1997 under "Number of dx or Mgmt options it states:

The number of possible diagnoses and or the number of mgmt options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

DG: For each encounter an assessment, clinical impression, or diagnosis shouldl be documented. it may be explicitly stated or implied in doucmented decisions regarding management plans and/or further evaluation.

Were these problems ( htn, lipids) addressed or considered in the providers management options.

Hope this helps.

 

[adweaver]

A status of these conditions was not listed. Labs are ordered under the diabetes dx as follows: (Lab: Renal Function
Hemoglobin A1c
Lipid Profile & LDL Cholestero
Ast/Alt
Thyroid Stimulating Hormone)

I'm thinking all of these labs are not for the diabetes but the documentation is showing that they are for the diabetes.

 

[rthames052006]

A status of these conditions was not listed. Labs are ordered under the diabetes dx as follows: (Lab: Renal Function
Hemoglobin A1c
Lipid Profile & LDL Cholestero
Ast/Alt
Thyroid Stimulating Hormone)

I'm thinking all of these labs are not for the diabetes but the documentation is showing that they are for the diabetes.

The labs you have listed could all be for the dx of DM and especially if the provider has given that information to you and is documented.

I may need to double check on the TSH but I know for sure that the dx of DM would be based on the NCD policies for those lab test under Highmark Medicare.