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.