Our physicians are creating a diagnosis section separate from a plan section. The diagnosis section only contains two or three of the actual diagnosis. The plan section is littered with diagnosis however, it is titled "plan". Can we code from "plan" as well as the diagnosis sections?
this is an example of what we are seing.
diagnosis
chest pain
copd exacerbation
plan
acute copd exacerbation
severe cough
lll loss of volume
-oxygenation stable
-contin advair
-prior hx...
-cont meds
-d/c med
UTI
-levaquin
Chest Pain 2' cough
-antitussive...prn
Hypothyroidsm
Tachycardia
-EKG
Hyperglycemia
-likely ...
I'm assuming you're asking about the Hypothyroidism, Tachycardia, and Hyperglycemia, since the other conditions listed are associated symptoms to the COPD and Chest pain, and wouldn't be coded separately...
First, you should find out if those diagnoses are confirmed, or if they're differential diagnoses (the word 'likely' by hyperglycemia makes it seem like it's a probable diagnosis, not a definitive one). If they're differential diagnoses, then they add a degree of complexity to the MDM under the #of diagnoses/management options section, but they're not counted as separate 'problems', unless A) they've been confirmed, AND B) they were addressed in the HPI, or in the exam somewhere.
Doctors can't get credit for listing conditions under the plan that seem to pop up out of nowhere at the end of the note - there needs to be some find of indication as to where they got that information...(How does he know about the tachycardia? Did they complain of palpitations? Did he do an EKG? Did he note a high pulse rate in his exam?) You need to know the whole story of each condition, to count it as its own condition for the E/M level, and the diagnoses must be confirmed, to assign them an ICD-9 code. You should probably confer with the physician, and ask him to make his thought process a little more evident to an outside observer. If you can't figure out what he was trying to say, chances are, an auditor wouldn't be able to either. Hope that helps!
