“STABLE” or “AS ABOVE” on a chart note

We often will see the physician document the patient’s condition with just the words “STABLE” or “AS ABOVE” on a chart note.  These words alone do not qualifty as a narrative documentation on that date of service about the condition.

This is from the SCAN HCC UniversityAsk a Coder:

I continuously have a doctor that puts ‘same’ in the diagnosis field of the EMR or he will put “same as x-ray findings” Is this allowable? If not, PLEASE help me to explain to him that it’s not.

A. There is no diagnosis code for “same”—I think that’s the best information you can give the physician. Diagnosis coding (or procedural coding for that matter) is always based upon the narrative documentation on this date of service. The physician must provide a narrative diagnosis on this date of service, in order for coding to be done. The physician is placing you and your organization at risk in the event of an audit. I suggest that you enlist the assistance of your manager or better yet, your organizations physician champion to counsel this physician about proper documentation.

 

Because for all we know they could be referring to this type of stable:

 

#HCC #ICD10 #CMS #ICD9 #RiskAdjustment #Career #MedicalCoding #Coding


 Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations.  The information presented herein is for general informational purposes only and is accurate as of the date of publication.