Evidence is vital in risk adjustment work, and not all evidence is the same, as we’ve blogged in the past. One area of growing concern is for conditions that may be permanent or which may improve and resolve. Let’s look at something like monoplegia or hemiplegia following a stroke. For some patients, weakness in part of the body responds to therapy and time, eventually resolving. Sadly, in some cases the damage to part of the patient’s brain results in permanent weakness.

A chart reviewer’s job is to determine the facts at the present time. For that reason, noting evidence such as a neurologist’s note is helpful but truly, the PCP’s exam of the patient at the time of the visit is the rock-solid proof. In addition, the exam should illustrate the findings, such as decreased strength, immobility, etc. not just “hemiplegia.” We always say that this is akin to saying the patient has a fever because he has a fever. You prove – if you will – the fever with an elevated temperature reading and thus, conclude the patient has a fever. In this case, the exam should work the same way. Describe the symptoms that support the condition called hemiplegia.

Another condition that comes to mind is purpura, the benign purple patches on the skin that many older people develop, which is not the same as the bruise we get from some sort of trauma. Purpura must be supported on the physical exam at the time of the visit, but sometimes we see general statements of “evidence,” such as that the patient reports bruising. This may sound like an unnecessary statement but we find it bears repeating: every condition listed in the assessment of a visit note must have been assessed at the visit. So, in the case of purpura, it should have been seen by the provider in person or on a telehealth visit and thereby assessed. If it’s not evident today, it shouldn’t be listed in today’s assessment.

The last example we’ll review is the case of angina pectoris. We recently reviewed a chart where the coder used evidence from a 2014 cardiology note to (try to) support that the patient had angina. Sometimes, we at CCG have to shake our collective heads ☹. Just because the patient had it in 2014 doesn’t mean he has it today. It just so happens that this patient eventually underwent stent placement to address his coronary artery disease, so the question is, is there a new blockage causing pain? Is the patient taking a specific medication to control anginal symptoms? These are issues addressed in the visit note and with some descriptive information, serve as evidence of the condition. For some background on angina, feel free to revisit this 2021 blog, which is still accurate.