tci Part B Insider - 2011 Issue 30

Reader Question: Documentation Should Support Diagnoses

Question: Our physician circled an initial diagnosis of COPD (chronic obstructive pulmonary disease) but during an audit I could not determine whether his documentation actually supported the diagnosis. Can you tell me what to look for in the documentation that would support a COPD assignment?Answer: Physicians will base an initial COPD diagnosis on several factors, and the best documentation will include extensive information about each factor. Most COPD documentation will include:In the HISTORY: Should include whether or not the patient had a history of cigarette smoking. The vast majority of COPD patients have a history of smoking cigarettes...

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