Ask An Expert: documentation
| Q: | A specialist’s consultation report came back three weeks after our patient had a face-to-face visit with the PCP, and revealed some new risk adjusted diagnoses. Can my PCP make an addendum and report them? |
| A: |
Probably not. An addendum is used when the patient was assessed for a condition during the visit and the PCP needed some additional information, to be received very timely, in order to make a definite diagnosis. Addenda are not used … Read Full Post |
| Q: | My patient has PVD, atherosclerosis of the lower extremities, and an AAA, which are all in HCC 105. I was told we need to document all three conditions even though there is only one payment for each HCC. Do I really need to waste of my time reporting all three conditions? |
| A: |
Yes, you do. The medical record is a legal document that must reflect all the conditions the patient has and their management. If the patient has all three conditions, they must all be documented and reported. From a purely payment … Read Full Post |