An acceptable problem list must show evaluation and treatment for each condition that relates to an ICD code. Simply listing every diagnosis in the medical record does not support a reported HCC code* and is unacceptable according to CMS. These four factors help providers establish the presence of a diagnosis during an encounter and ensure proper documentation. T: Treat-medications, therapies, other modalities M: Monitor-signs, symptoms, disease progression, disease regressionĮ: Evaluate-test results, medication effectiveness, response to treatmentĪ: Assess/Address-ordering tests, discussion, review records, counseling Each diagnosis must be documented in an assessment and care plan and each diagnosis must show that the provider is Monitoring, Evaluating, Assessing/addressing or Treating the condition: This simply means that diagnoses cannot be wholly determined from test results and a patient’s past medical history.Ī well-documented progress note would include the HPI, ROS, physical exam and show the medical decision-making process. Physicians must accurately document each patient diagnosis and the diagnosis MUST be based on clinical medical record documentation from a face-to-face encounter. The Official ICD Coding Guidelines state that a condition must be present at the time of the encounter, affect patient care or management and be clearly documented in order to be coded as a diagnosis.
21, 2018 / By Kelly Long, BS, CPC, CPCO, CAPM
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