] One time mention by consult and not the attending...what do you all do?
Some people have asked for supporting documentation of why each and every progress note must contain all diagnoses under current clinical management by the physician. An E & M service is the exchange of clinically relevant and necessary information between the patient and/or caregiver and the use of this information in the clinical management of the patient. The lack of a diagnosis or diagnoses in the daily progress note is problematic from two points, the Medicare reviewer cannot validate that the service is reasonable and necessary,a requirement for all services provided to Medicare beneficaries.The second point is that without a diagnosis or diagnoses documented, one is not able to tell what conditions the physician is clinically managed and by definition how can there be an E & M service without the physician actually managing conditions.
See the following links for carrier and MAC probe reviews outlining requirements for validation of E & M services provided and billed by physicians in the hospital setting. Hope this helps.
Thank you
http://wpsmedicare.com/part_b/departments/medical_review/2010-1025-99233-spec08.shtml
http://www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1&ID=14514
-----Original Message-----ces
>From: CDI Talk
>Sent: Sep 12, 2011 2:42 PM
>To: glennkrauss@earthlink.net
>Subject: RE: [cdi_talk] One time mention by consult and not the attending...what do you all do?
>
>
>Could you please tell me where you obtained the information in regards to your statement if the diagnosis is not documented every day the physician is managing for free from his/her E & M perspective. I attended a telephone conference once that said if a doctor does not document a any diagnosis that they could not be billing. I can not find where that information was obtained. We have some physicians that do not document a diagnosis at all daily.
>
>Thank you
>
>-----Original Message-----
>From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
>Sent: Friday, September 09, 2011 10:36 PM
>To: Trygar, Cheri E.
>Subject: [cdi_talk] One time mention by consult and not the attending...what do you all do?
>
>One point to be made about consistency of documentation from the physician's perspective, whether the consulting physician or the attending physician is managing the clinical condition in question. If the physician is managing a condition such as thrush and only documents the condition once, then that means he/she can only count the diagnosis on the condition was documented as part of the medical decision making process for E & M assignment, this despite the fact of clinical decision making to continue the meds beyond the first day the diagnosis was written in the chart. Medical decision making consists of three components, number of diagnosis and management options, amount and complexity of data and table of risks. If the diagnosis is not documented every day the condition is continued to be actively managed, the result is the physician is managing a clinical condition basically for free from his/her E & M perspective.
>
>Hope this helps, it certainly works for me in discussing the merits of consistent clinical documentation to physicians and NPP.
>
>Thank you
>
>
>
>-----Original Message-----
>>From: CDI Talk
>>Sent: Sep 9, 2011 9:58 AM
>>To: glennkrauss@earthlink.net
>>Subject: [cdi_talk] One time mention by consult and not the attending...what do you all do?
>>
>>There is a constant struggle with 1 time mention in the chart of a diagnosis, especially if it the only cc by the consultant and not by the attending. Attending never picks up the additional diagnosis and the consultant never mentions it again.....and worse...not show up in the D/C Summary
>>
>>Case in point. Patient was admitted with AE COPD. Pulmonologist documents thrush - start nystatin swish/swallow. Do you query the attending if he agrees with the thrush dx or do you not query. What you do?
>>
>>- Christina
>>---
>>CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>>
>>You are receiving this message as a member of CDI Talk as: glennkrauss@earthlink.net
>>If you would like to be removed from CDI Talk, please send a blank email to
>>leave-cdi_talk-11551594.832b8c147a2b8ab21fc91edd9c8c82b4@hcprotalk.com
>>---
>>Copyright 2010
>>HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
>
>
>---
>CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
>You are receiving this message as a member of CDI Talk as: ctrygar@mth.org
>If you would like to be removed from CDI Talk, please send a blank email to
>leave-cdi_talk-10992099.55749ef34f2a07e2173a7854a30d81be@hcprotalk.com
>---
>Copyright 2010
>HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
>
>---
>CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
>You are receiving this message as a member of CDI Talk as: glennkrauss@earthlink.net
>If you would like to be removed from CDI Talk, please send a blank email to
>leave-cdi_talk-11551594.832b8c147a2b8ab21fc91edd9c8c82b4@hcprotalk.com
>---
>Copyright 2010
>HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
>
See the following links for carrier and MAC probe reviews outlining requirements for validation of E & M services provided and billed by physicians in the hospital setting. Hope this helps.
Thank you
http://wpsmedicare.com/part_b/departments/medical_review/2010-1025-99233-spec08.shtml
http://www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1&ID=14514
-----Original Message-----ces
>From: CDI Talk
>Sent: Sep 12, 2011 2:42 PM
>To: glennkrauss@earthlink.net
>Subject: RE: [cdi_talk] One time mention by consult and not the attending...what do you all do?
>
>
>Could you please tell me where you obtained the information in regards to your statement if the diagnosis is not documented every day the physician is managing for free from his/her E & M perspective. I attended a telephone conference once that said if a doctor does not document a any diagnosis that they could not be billing. I can not find where that information was obtained. We have some physicians that do not document a diagnosis at all daily.
>
>Thank you
>
>-----Original Message-----
>From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
>Sent: Friday, September 09, 2011 10:36 PM
>To: Trygar, Cheri E.
>Subject: [cdi_talk] One time mention by consult and not the attending...what do you all do?
>
>One point to be made about consistency of documentation from the physician's perspective, whether the consulting physician or the attending physician is managing the clinical condition in question. If the physician is managing a condition such as thrush and only documents the condition once, then that means he/she can only count the diagnosis on the condition was documented as part of the medical decision making process for E & M assignment, this despite the fact of clinical decision making to continue the meds beyond the first day the diagnosis was written in the chart. Medical decision making consists of three components, number of diagnosis and management options, amount and complexity of data and table of risks. If the diagnosis is not documented every day the condition is continued to be actively managed, the result is the physician is managing a clinical condition basically for free from his/her E & M perspective.
>
>Hope this helps, it certainly works for me in discussing the merits of consistent clinical documentation to physicians and NPP.
>
>Thank you
>
>
>
>-----Original Message-----
>>From: CDI Talk
>>Sent: Sep 9, 2011 9:58 AM
>>To: glennkrauss@earthlink.net
>>Subject: [cdi_talk] One time mention by consult and not the attending...what do you all do?
>>
>>There is a constant struggle with 1 time mention in the chart of a diagnosis, especially if it the only cc by the consultant and not by the attending. Attending never picks up the additional diagnosis and the consultant never mentions it again.....and worse...not show up in the D/C Summary
>>
>>Case in point. Patient was admitted with AE COPD. Pulmonologist documents thrush - start nystatin swish/swallow. Do you query the attending if he agrees with the thrush dx or do you not query. What you do?
>>
>>- Christina
>>---
>>CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>>
>>You are receiving this message as a member of CDI Talk as: glennkrauss@earthlink.net
>>If you would like to be removed from CDI Talk, please send a blank email to
>>leave-cdi_talk-11551594.832b8c147a2b8ab21fc91edd9c8c82b4@hcprotalk.com
>>---
>>Copyright 2010
>>HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
>
>
>---
>CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
>You are receiving this message as a member of CDI Talk as: ctrygar@mth.org
>If you would like to be removed from CDI Talk, please send a blank email to
>leave-cdi_talk-10992099.55749ef34f2a07e2173a7854a30d81be@hcprotalk.com
>---
>Copyright 2010
>HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
>
>---
>CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.
>
>You are receiving this message as a member of CDI Talk as: glennkrauss@earthlink.net
>If you would like to be removed from CDI Talk, please send a blank email to
>leave-cdi_talk-11551594.832b8c147a2b8ab21fc91edd9c8c82b4@hcprotalk.com
>---
>Copyright 2010
>HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945
>