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Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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brownlee47
Posts: 54
Joined: Wed Aug 27, 2014 1:32 pm

Tue Mar 08, 2022 2:55 pm

Can you clarify if it ok to list a dx in the assessment and plan if you didn't address the issue but you refilled the meds or requested a referral. The additional codes did not have an impact on the level of care. but because it was part of the referral its on the claim.
In one of our audits, the auditor dings us for having the dx in the a/p however the level of service is validated by the dx that are addressed.
Shoshana
Posts: 92
Joined: Fri Jun 23, 2017 1:41 pm
Location: Multi-specialty Clinic

Thu Aug 04, 2022 12:56 pm

Is your A/P separate on the template? Sometimes my doctors will list diagnoses in the assessment, but put treatment in the plan without connecting it to the diagnoses he means it should go with. My coders are not allowed to assume, i.e. HTN in Assessment with Lisinopril QD in the plan. They do not assume these go together because many drugs are used for different disease processes, i.e. Farxiga (diabetes) and (kidney disease). The physician should connect what he is doing with the disease process it goes with.

I don't know if this is what you were asking, but this is how I read your question.
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