Wiki Documenting medication refills

[m.matos@chcfl.com]

On our progress notes under assessments there is an area for "Other"
In this area I am finding where providers have given refills but they have not selected a dx for the refill to go with and I do not see documentation for the condition in the present progress note. The dx that these meds go with are on the pts problem list but this problem list does not show in the progress note for that day. It is in another area of the chart.

Is it safe to say that anytime refills are being done the provider should provide a dx and there should be documentation of this condition in the present visits progress note?

 

[ljulien]

Yes, you need an assessment. This is a common problem with EMRs. In order to give credit appropriately, an assessment should be documented along with a status and plan (in this case the med refill). I would not recommend using a diagnosis listed in a problem list. There must be support within the progress note. Either query the provider for the appropriate diagnosis with support or do not give credit.

 

[m.matos@chcfl.com]

So if documentation and dx is missing to support the refill, I can just not give credit for this and move on or should I be requiring the provider to do an addendum to the progress note and provide the documentation and dx?

And I am not pulling dx from the problem list. The Provider is addressing conditions they find on the progress note and giving refills but not provider any documentation in the progress note to support the refill.

 

[m.matos@chcfl.com]

And Thank you for your response.

 

[ljulien]

An problem listed in your problem list (usually at the beginning of the note) and a refill listed at the bottom of your note somewhere is not going to sustain an external audit if that should happen. There must be supporting documentation within the note.

Whether you query the provider for more info or to add an addenum or you do not give credit for the poblem (list) med refill will have to be a decision based on your internal coding policy.

I would err on the side of caution and not give credit. You will need to educate your providers on medical documentation requirements supporting the 1995/1997 E/M Guidelines as well as educate on the pitfalls of the EMR. There are many resources out there to help you with this including AAPC.