Wiki Specificity for New E/M changes 2021

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haleyhoffman

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How specific do providers need to be in there plan for these new changes? My providers are listing the patients diagnoses then underneath that they list there "plan." In the plan they will list continue viibryd for depression or continue Adderall for ADHD. In there diagnoses list they list major depression, recurrent, moderate and ADHD, combined type. We are receiving feedback that the providers need to be more specific in there plan and it needs to match the description of the diagnoses listed. So it needs to say continue viibryd for major depression, recurrent, moderate and Adderall for ADHD, combined type. Has anyone else heard this about the new changes? We feel this is redundant for the providers to have to document it like that in both places.
 
So the diagnosis is more specific in the problem list than it is in the plan? As one shouldn't code from a problem list, I would agree that the providers should be as specific as possible when documenting the problems addressed in their plan. This is not new for 2021, but rather a best practice for documentation.
 
In my opinion, your doctors are doing what they need to do. I'm not a psychiatrist but unless they were to list multiple diagnoses for depression, if there is such a thing, or ADHD for the patient, stating that a certain drug was for the single type of depression or ADHD listed, why should they have to repeat all the specifics of the type of depression or ADHD again when they list the prescription drugs for the patient as long as they have said a specific drug is for depression or the ADHD?

Just my 2 cents worth as a provider.

Tom Cheezum, OD, CPC, COPC
 
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