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Diagnosing the Difference: Assessments vs Problems: Part 2

Hello again. Here’s a hypothetical scenario that will help to illustrate the importance of using problems and assessments correctly to ensure your providers are properly credited for all care provided.

Bonnie Bunny has been Dr. Farmer’s patient at Rabbit Community Health Center (RCHC) for the past five years, and was diagnosed with hypertension three years ago. Dr. Farmer put her on ACE inhibitors two years ago to help manage her condition. Fifteen months ago she had her LDL tested because Dr. Farmer suspected high cholesterol was affecting her hypertension. A visit a month ago was the third one this year at which her blood pressure registered in control.

Unfortunately, Dr. Farmer doesn’t properly maintain the problem list, so Bonnie only has hypertension assessments. As part of a managed care contract, RCHC receives clinical quality dollars for controlling their hypertensives’ blood pressure. But when the center’s quality improvement (QI) team examines their “Hypertension Blood Pressure Control” measure, Bonnie is missing from it. Since her blood pressure was in control, the QI team wants to ensure that patients like her are included in the measure, as that positively impacts the measure result and demonstrates the high quality care RCHC provides to its patients. So, why is Bonnie Bunny not counted as hypertensive?

We must we focus on what the difference is between an assessment and a problem. Part 1 of this blog series explained that an assessment documents a diagnosis that is present or addressed at the time of the visit, while a problem documents a diagnosis that affects the patient over an extended period. With this difference in mind, let’s go back to the example of Bonnie Bunny. 

With only assessments in Bonnie’s chart, her hypertension diagnosis exists as a series of points at which we know she was hypertensive.

But since her last assessment was 15 months ago for an LDL test, she would not appear in a search of “active hypertensives” recorded in the past year.

Now, a patient whose blood pressure is in control and is in the measure’s numerator is not counted in the denominator, so the center’s measure results suffer. Imagine if Dr. Farmer had recorded Bonnie’s diagnosis as a problem alongside the assessment when she was diagnosed three years ago. As an active problem, the diagnosis is open ended. 

If you look for “active hypertensives” in the past year, she would appear as hypertensive because of the active problem. This way, RCHC is credited for all the care Bonnie received and for the benefits of a treatment it prescribed in prior years.

By adding the diagnosis to the problem list, the provider has documented the fact that the patient is/remains hypertensive even though he or she hasn’t recently been billed for that care. Patients with hypertension, diabetes, ischemic vascular disease, and asthma often maintain a course of treatment for several years at a time without a modification that may not require a billable diagnosis. Proper use of problems ensures health centers are credited for the full population of patients they serve, particularly when improvements in the patient’s health result from a course of treatment that was determined at some point in the past.