Let’s play a game…I am going to list the diagnoses on the Assessment section of a specialist’s consult note in the order he listed them, and you try to guess the provider’s medical specialty:

  1. Paroxysmal atrial fibrillation
  2. Coronary artery disease
  3. Hypertension
  4. GERD
  5. Gastric polyps
  6. GI bleed
  7. Chronic kidney disease
  8. Hyperlipidemia
  9. Diabetes
  10. Hypogonadism
  11. Iron deficiency anemia

We’re going to pause our game to review two relevant topics, starting with the purpose of the assessment section of the note. As we’ve explained in the past, the SOAP note has a specific format and the information in early progress note sections – such as the chief complaint; history of present illness; past medical, family, social history; review of systems; and examination – culminates in the medical conditions that are listed as being assessed during the visit. To quote a former client….

She, incredulously: “You mean I have to assess the conditions I list in the assessment?”

Me: “Yes, ma’am. That’s why they call it an assessment.”

Now, let’s recall the documentation and coding rule of the primary, or first-listed, diagnosis. This is the condition that dominates the provider encounter, is the main reason for the visit, and the issue that occupied the majority of resources at the visit.

So, by looking at the list above, you could assume this note was documented by a primary care provider, who is responsible for the first-line management of a variety of medical conditions. But remember, I said it was a specialist’s note. What we see above – loosely speaking – are cardiac conditions (#1, 2, 3, 8?), GI conditions (#4, 5), endocrine (#9, 10, maybe 8), nephrology (#7) and hematology (#11, which could also be under investigation by GI). If we consider the first listed condition, you’d think – hands down – this is a cardiac or electrophysiologist note. Would it surprise you to know this provider is a nephrologist? My mind was certainly blown!

If the provider must make an assessment of the conditions listed in the assessment, how then is the kidney doctor assessing the status, disease progression/regression, treatment efficacy, etc of the first six conditions? He’s not. And we see this scenario all the time.

While the nephrologist may need to consider the patient’s coexisting conditions for his management and treatment of the kidney disease, he is not assessing or treating those other diagnoses. For that reason, he should use the HPI section of the note for a discussion of the impact, say, hypertension or diabetes have had on the patient’s kidneys. Those conditions, then, would not be coded as part of the visit because they’re not being assessed or managed. Additionally, when determining the E/M level of the visit, those non-nephro diagnoses would not factor into the AMA’s requirement for the visit code selection.