In this four-part series, we’ve explored so far, the use of suspect reports and issues related to prior medical records. In this installment, we’ll look at what can make specialist notes a little challenging to the chart reviewer.
Although the scope of primary care is broad, it’s obviously not as deep as that for a provider who receives additional training in a subspecialty, resulting in greater expertise. Of course, PCPs diagnose conditions that fall under subspecialties like cardiology, pulmonary and gastroenterology, all the time, but in some cases, the standard of primary care includes referral to a specialist.
Specialist reports can contain a wealth of MRA information that is helpful to the reviewer. However, over the years, we’ve learned to take those notes with a grain of salt for the reasons below.
Sometimes providers list diagnoses that are differential – meaning they’re not yet confirmed – as the justification for ordering and/or performing tests. It’s important for the reviewer to carefully read the specialist’s note and evaluate whether the “breadcrumbs” for the diagnosis are spelled out in the note. An example that we encounter with great regularity is the diagnosis of angina. When a cardiologist diagnoses this condition in the absence of any documented findings from the HPI, ROS or exam, it’s suspect for us. In addition, if the only things documented in the plan are orders for testing, this is usually not a valid diagnosis. We can’t take a specialist’s note at face value without reading for the context to assure the condition is valid and active. As non-coders, clinicians may not be cognizant of the differences between inpatient and outpatient coding, and report working diagnoses in error.
Another example is the oncologist visit where the provider codes a cancer diagnosis. However, the rest of the note goes into great length about the treatment the patient received in the past, often a decade earlier, and mentions there’s been no recurrence. Sometimes, the oncologist also writes “no evidence of disease” yet he or she does not use the personal history of cancer code. Again, these are red flags that just because a specialist said it in a note doesn’t make it code-able.
The last example is the specialist who lists conditions that are not under his/her medical specialty. An example is the gastroenterologist who lists in the assessment Crohn’s disease (a GI condition) along with heart failure and COPD, which are not under the GI specialty. It would be incorrect to use the GI note as evidence of heart failure and COPD. The reviewer must look for other proof – especially from a specialist in that field – to corroborate the condition.
Join us for the final installment of this four-part series where we’ll discuss the bottom line.