Additional Visits

[nurseshots]

when an additional visit is made we document at the top of the note scheduled visit? no explain___(example: av to assess patient cardiac status). then under primary or pertient diagnosis: we put only the primary dx like dm ii.

my question is when you make an av, it is for a specific reason. not a "routine visit", so ur in the home assess patient, possible call md-report b/p status...etc. or even short visit because pt is sent to er..whatever....

is it true? neccessary? required? or what ? that you not only document assessment, actions, blah blah on cardiovascular...da da..but also document teaching/education on dm ii or whatever the primary dx happens to be?

or visit is: not a billable visit, won't get paid for the visit if teaching of primary not on note, every note must contain teaching on primary dx no matter what?

help!

[caliotter3]

Also interested in reading what is done in these situations.

[berube]

my understanding is as long as some aspect of teaching is done you are OK,,,the pt obviously has co-morbidities and therefore you would be teaching on various disease processess on different visits, usually they are all intertwinned....NEVER heard of that being a non billable visit.