KStaten
Guru
This is yet another crazy question, but please bear with me.
If a provider is very brief in his / her documentation for the plan, can information be pulled by the coder from elsewhere in the note, even if the provider does not specifically link it to his/ her medical decision making for the problem at hand.
Example: A patient is being seen for a yearly follow-up of a joint replacement (outpatient) and the doctor ONLY documents the plan as such:
"The patient is doing well with her joint replacement. I will see the patient in a year." (No suggestions for OTC medicine, PT, nor intervention of any kind nor concerns of other health problems)
If, however, when searching the note, it is documented in the patient's problem list (collected previously) that the patient is a diabetic, has cardiac issues, etc can this be considered when choosing the level of MDM for the E/M level even if the provider does not document that the other health factors factor into the continued care for the problem currently being treated? For instance, I would consider this a 99212 based on the plan, but could the provider justify it being a 99213 simply because the patient has other health problems in their problem list, even though no documentation suggests concerns nor special treatment / precautions?
THANK YOU! I appreciate your input greatly!
If a provider is very brief in his / her documentation for the plan, can information be pulled by the coder from elsewhere in the note, even if the provider does not specifically link it to his/ her medical decision making for the problem at hand.
Example: A patient is being seen for a yearly follow-up of a joint replacement (outpatient) and the doctor ONLY documents the plan as such:
"The patient is doing well with her joint replacement. I will see the patient in a year." (No suggestions for OTC medicine, PT, nor intervention of any kind nor concerns of other health problems)
If, however, when searching the note, it is documented in the patient's problem list (collected previously) that the patient is a diabetic, has cardiac issues, etc can this be considered when choosing the level of MDM for the E/M level even if the provider does not document that the other health factors factor into the continued care for the problem currently being treated? For instance, I would consider this a 99212 based on the plan, but could the provider justify it being a 99213 simply because the patient has other health problems in their problem list, even though no documentation suggests concerns nor special treatment / precautions?
THANK YOU! I appreciate your input greatly!