Welcome back to the Compliance Blog!
We are happy to have you here for the February 2024 Compliance Blog! This month, we are talking more about Medical Coding and Documentation. o
Let’s talk Medical Coding and Documentation!
Documentation serves as an important record of what is discussed during a visit between a provider and a patient. It can also affect the visit code that should be used for a visit as well as any diagnosis code(s) given during that encounter.
The rule of thumb is that if you discussed it during the visit, treated it, or if it affected how you’re treating the patient, you should document it and then code it. This goes for medications (including over-the-counter medications recommended), chronic illnesses the patient has, or personal or family history that could affect the treatment plan for a patient. This doesn’t mean the patient’s note has to be very long or exhaustive, but make sure you include enough information behind why some decisions were made for patient treatment if they occurred.
Breaking it down further with an example:
A patient with hypertension comes in with the flu, you discuss how their blood pressure may rise due to being sick and recommend over-the-counter medications for symptom care and send them home. The note could be “Patient with flu, sent home”, but a more accurate way to describe what happened and also reflect the risk level associated with the patient would be something like “Patient w/ history of HTN here with flu, urged importance of measuring BPs while sick and recommended OTC acetaminophen and ibuprofen for symptom relief and fever”. For both charts, the visit with the patient was the same; the only difference is that the second note documented what they talked about with the patient in more detail and highlighted other risks for the patient. The visit code for the first chart would be a 99202 or 99212 since no treatment or risks were documented, but the second chart would get a 99203 or 99213 since the over-the-counter medications were mentioned. The second chart could also include hypertension as a diagnosis for the visit since it was documented as discussed and it affected how the patient should treat their flu.
We are Here to Help!
If you have any questions about any of these, please feel free to reach out to our Medical Coder, Lena Sadler, via Teams and/or email at LenaSadler@healthpoint-tx.com.
