How many times must a physician document a diagnosis? A Different Perspective
I have been reading these posts on how many times must a physician document a diagnosis. One key concept being overlooked is that the physician's clinical documentation is not just for hospital coding. The physician's E & M assignment for his/her work performed including time as well as cognitive skills is directly supported and impacted by the level of specificity in clinical documentation. The three components of medical decision-making under E & M guidelines are number of diagnoses and management options, amount and complexity of data and table of risks. All current clinical conditions being actively treated, evaluated and monitored by the clinician must be documented, including stability of the patient, i.e., acute, chronic, improving,etc., must be documented each and everyday they are being addressed. Otherwise they cannot be counted toward the MDM component of E & M.
Aside from E & M assignment, following sound documentation practices each and everyday in every patient encounter is a responsibility and duty of the physician. Their documentation is vital to supporting the medical necessity for seeing the patient, both from an intensity and frequency of service standpoint. More and more physicians are finally realizing that medical necessity is a concept impacting their own business, not just that of the hospital, as they receive ADR letters from Medicare asking for copies of their notes before deciding if the encounter will be paid.
In essence, the answer to the question of how many times a physician must document a diagnosis hinges on how many days the patient is being treated for the clinical condition. As long as the patient is being treated for aspiration pneumonia, the diagnosis should be documented each and everyday.
Aside from E & M assignment, following sound documentation practices each and everyday in every patient encounter is a responsibility and duty of the physician. Their documentation is vital to supporting the medical necessity for seeing the patient, both from an intensity and frequency of service standpoint. More and more physicians are finally realizing that medical necessity is a concept impacting their own business, not just that of the hospital, as they receive ADR letters from Medicare asking for copies of their notes before deciding if the encounter will be paid.
In essence, the answer to the question of how many times a physician must document a diagnosis hinges on how many days the patient is being treated for the clinical condition. As long as the patient is being treated for aspiration pneumonia, the diagnosis should be documented each and everyday.
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Donna