I would like to know what the rule is on this: A provider documents an encounter with pertinent HPI, ROS, Exam, etc., but during the course of the encounter note doesn't document to the highest level of specificity regarding the diagnosis. Now he or she comes to the step in EHR charge capture where he or she selects the proper diagnosis (from a provider perspective). The
diagnosis code selected by the provider is far more specific. For example, the diagnosis code may select the type of infection, the type of diabetes and its complication, or the name of the disease process he or she arrived at.
My question is, when auditing this note for proper coding, does the provider's documentation need to specifically state these things before arriving at the assessment part (where our EHR lists the diagnosis based on the code selected by the provider)? Or is it assumed (such a scary word in an audit) that when the provider selected the
diagnosis code, he or she intended that further specificity to round out the documentation?
I am leery of shrugging my shoulders and saying, "Doctor knows best," but I also need some ground to stand on when going to the provider to ask for more clarity in his or her documentation.
Please help!
Meri, CPC, CEMC