Just as location is important to a realtor, diagnosis documentation should be important to billing E/M services. Don’t lose sight that the documentation does not need to include a diagnosis pulled from a previous visit or previous diagnosis that does not affect the current illness or treatment plan.
It is always important to remind the provider to stay focused on the diagnosis for the current date of service for which is the reason for the visit. CMS E/M Services guide confirms, “The number of possible diagnosis…to consider is based on…the number and types of problems addressed during the encounter.”
Two reasons to include the diagnosis:
- Patient presents to the clinic for the diagnosis.
- Diagnosis directly impacts treatment plan for the presenting problem. There may be times that the provider will need to consider other diagnoses and current medications before being able provide treatment for the presenting problems.
When you are coding the annual visit and/or medication management visit, all current diagnosis that are managed by the provider (billing) should be included in the documentation.
It can be very confusing for the coder when all the diagnoses are included in the documentation for every visit. When the provider includes all the diagnoses it can be difficult to determine which diagnoses were actively treated and what is just an active problem only. Do not include the diagnosis if it does not impact the presenting problems.
All providers need to be reminded that by providing the appropriate diagnosis it leaves no room for speculation or assumption. This will help the coder more accurate calculations for the E/M Level service.