Wiki SO many dx for a routine visit

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klp010102

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I have a provider that will see a patient for say "back pain". Entire note talks about back pain. Then you get down to the DX and she will have 12 DX. Usually it is all chronic conditions that she maybe running labs on. It is driving me nuts. How do you handle this with your providers? I need the DX to justify the labs but it makes the documentation so hard to read and complicated. It just doesnt flow.

Any suggestions? :mad:
 
I have the same problem with one Doctor at my practice! In this case, I would use back pain as the primary diagnosis b/c that's what is documented in the notes. I would then go to the Doctor and ask him/her why the labs were requested and explaine that they need to put more specific documentation in the notes to support why specific labs were ordered: listing the diagnosis is not enough. I ALWAYS go to my Doctors when I come accross any situation like this-if need be, they do an addendum and include why the labs were ordered- ie: 'Patient has history of fatigue, joint paint, and was bitten by a tick 2 years ago which resulted in bulls-eye type rash. Patient did not seek medical attention for this until today when symptoms of Lymes Disease began appearing and therefore I have ordered labs to check for a positive diagnosis of Lymes Disease'. This is ONLY an example. I always try to remember that the notes HAVE to support medical necessity and if they do not, I go back to the Doctor and explaine that it does not support medical necessity and needs to be addressed.
I hope this helps!!!
Marje
 
Yes I understand....this is exactly what I have been doing. It just makes it so confusing because then I'm holding the ticket waiting on an answer etc...

basically it just goes back to better training for the providers and reinforcing it over and over. Like having a child LOL. I have tickets everywhere waiting on them to be corrected
 
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