Wiki Documentation query

[ndanh01]

The Providers at our practice code their own charts, the physicians pick the diagnosis and the system automatically adds it to the assessment.

For instance, lets say... A patient has diabetes with a manifestation. The physician completes the hx and exam and would code the dx by picking a description that has a code attached, this shows up in the assessment part of the chart notes.

The physician does not ever state in the other section of the chart notes that the pt has diabetes with macular edema. When the physician chooses the dx and it populates in the assessment section of the E/M chart it looks like this...

Assessment: 250.XX-diabetes with macular edema

Nowhere else in the chart note does it state the pt has diabetes with macular edema. Is this sufficient enough to code the the diabetes with macular edema? Or would diabetes and macular edema be coded separately? The other parts of the chart notes do not specify the causal relationship but, it is stated in the assessment by the dx description.

The physician list in his assessment the dx and the code but, doesn't he/she have to state that also in the documentation somewhere?

Any feedback and thoughts would greatly be appreciated.
Thank You,
Leppie

 

[mitchellde]

Coding clinic 1st quarter 2012 states that the provider may not use the DX code with its descriptor as a substitute for the rendered diagnosis. The diagnosis must be rendered in the providers own words. So I would not code a diagnosis found only in the assessment and not re fenced in the note.

 

[ndanh01]

Thank You! If I were to subscribe to the coding clinic right now will I have access to that specific one you just referenced? Besides coding clinic, would this guideline be referenced anywhere else?

 

[mitchellde]

You would still need to purchase the past issue. I do not know of any other place this would be referenced.