![]() ![]() Following these documentation principles will ensure accurate documentation, improve patient care delivery and data integrity by validating diagnosis codes while reducing risk to the organization.The Emergency Medical Technician (EMT) Program at Mt. A list of diagnoses is not acceptable evidence that the diagnosis affected patient care. ![]() Each diagnosis listed should be properly documented with evaluation and/or treatment. Any condition addressed or considered as relevant to treatment at the time of the encounter should be documented in the Assessment and Plan. criteria helps ensure that documentation satisfactorily meets CMS’s requirements for supported diagnoses. This can lead to a denial of payment which can be averted if the condition exists, is still being treated and is PROPERLY DOCUMENTED. But there is a caveat, however, that should not be overlooked stating “history of” is often interpreted by CMS and their Recovery Audit Contractors to mean the patient no longer has that condition. For example: a history of melanoma when ordering a biopsy for suspicious skin lesions. It is acceptable to include “history of” conditions if it affects the current treatment plan. Prostate CA: 185 - no change in condition, being seen by Dr.DM: 250.00 - stable on meds, no complications noted, order labs.Increase dosage to 50 mg daily and monitor. Major Depression: 296.30 - continues to experience feelings of despair and grief despite current medication.Atrial Fibrillation: 427.31 - controlled with Warfarin.Many providers misconstrue or assume that having a list of active conditions listed and stated as reviewed is sufficient documentation, until a RAC audit reveals the paucity of clinical evidence supplied.Īccording to CMS, an acceptable problem list in the assessment must show evaluation and treatment for each condition that relates to an ICD-9 code. Proper documentation of each diagnosis will demonstrate that the provider is Monitoring, Evaluating, Assessing or Treating the condition.Ī list of diagnoses, as often found in progress notes, is not acceptable or valid per official coding guidelines, nor does this meet the definition of an Assessment and Plan. Each diagnosis should be documented in the assessment and plan. Treat-medications, therapies, other modalitiesĬMS-accepted providers should document all conditions evaluated and considered during treatment for each face-to-face encounter. ![]()
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