As many clinical quality measures (CQMs) focus on patients with specific diagnoses, identifying patients with an “active diagnosis” is extremely important. It’s often difficult to determine which patients belong to a particular diagnosis population. This is due to a misunderstanding of the intent and use of two different forms of EHR diagnoses (the way a diagnosis is documented within the EHR): ASSESSMENTS and PROBLEMS. In this series we’ll clarify the differences between these two ways to document a diagnosis, and we’ll illustrate the implications of the differences.
An ASSESSMENT documents a diagnosis present or addressed at the time of the visit – a codified version of the “reason for visit,” entered during scheduling. This could include chronic conditions such as diabetes (E11.*); acute conditions such as a broken arm (S52.*); symptoms such as wheezing (R06.2); procedures such as a pregnancy test (Z32.*); or even dietary counseling (Z71.3). Assessments are generally used to justify a diagnosis for any charges associated with a specific visit, and are sent to health plans, lab vendors, and HIEs alike. Assessments are relatively simple data points; they include only an assessed date and a diagnosis code. This means ASSESSMENTS are associated with a visit, and pertain only to what occurred during that visit.
Conversely, a PROBLEM documents a diagnosis that affects the patient over an extended period – a codified version of the specialty of care they receive. This typically includes chronic conditions, and historical conditions that may impact patient care. For example, both depression (F33.*) and history of mental disorders (Z86.59) belong on the PROBLEM list. The advantage of adding a diagnosis as a PROBLEM is it remains in the patient’s medical record and can have its onset, diagnosis, and resolved dates tracked as discreet data points. Since a PROBLEM can cover time between visits, a PROBLEM is associated with the episode of care, and doesn’t divulge whether a patient was treated for the condition during a specific visit.
Any certified EHR will support both methods, and health centers are strongly encouraged to document diagnoses in both ways, when appropriate, to avoid a wide range of issues. Inconsistent ASSESSMENTS use can cause rejected claims and reduced reimbursements; Inconsistent PROBLEM list use can cause poor care coordination across a care team, and difficulty determining which patients have specific chronic conditions. In our next post we’ll explain how the improper use of ASSESSMENTS and PROBLEMS affects the calculation of CQMs.
Samuel Bar in an implementation specialist at Azara Healthcare.