Emily McLaughlin asked:
When an MD puts " Not significant" in the History section of a report; is this sufficient in terms of documentation standards?
Also: Can an MD note "negative except as documented in HPI" in the ROS?
Thank you for your input.
Answer:
Not significant is not sufficient from a coders standpoint. However; the second statement you give when the HPI and or other parts of documentation are reference that is excellent. Because it shows that it is addressed.
I found a couple articles that I think you will find interesting. does not address exactly what you are asking but it allows for the need in documentation and the role of the coder vs the provider.
<https://www.medpartners.com/guideline-19-code-assignment-clinical-criteria/>
<https://www.aapc.com/blog/26957-undercoding-is-no-better-than-overcoding/>
When an MD puts " Not significant" in the History section of a report; is this sufficient in terms of documentation standards?
Also: Can an MD note "negative except as documented in HPI" in the ROS?
Thank you for your input.
Answer:
Not significant is not sufficient from a coders standpoint. However; the second statement you give when the HPI and or other parts of documentation are reference that is excellent. Because it shows that it is addressed.
I found a couple articles that I think you will find interesting. does not address exactly what you are asking but it allows for the need in documentation and the role of the coder vs the provider.
<https://www.medpartners.com/guideline-19-code-assignment-clinical-criteria/>
<https://www.aapc.com/blog/26957-undercoding-is-no-better-than-overcoding/>
Last edited: