Wiki Help with written proof notes must support the level of specificity for the diagnosis

cubbiecatz

Networker
Messages
64
Location
Tulsa, OK
Best answers
0
I have been requested by a physician to show her in writing where her notes (HPI) must reflect the specific diagnosis she is choosing and why the diagnosis code isn't enough. The issue in debate is her picking mixed hyperlipidemia, but in the HPI she is stating patient has hyperlipidemia, nothing else other than maybe it's stable, but nothing to support how mixed or pure, was known to be the specific diagnosis.
My understanding has always been the notes have to support the final diagnosis and the doctors opinion is that I am wrong so she wants to see it in black and white. Nothing I have said or explained made a difference. The doctors also believe we will never get hit with an audit so they don't understand why it's so important to follow the rules and requirements.

Can anyone help?

Thank you, Cathy Satkus, CPC
 
Top