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Question: One of our physicians is not putting diagnoses on their on-treatment visit (OTV) note. They are just noting the treatment site and would like coders to figure out the diagnosis — if it is metastatic versus primary versus benign — to save time. The physician would like proof that it needs to be documented. Any advice would be great.

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Answer: An OTV note is like any other office visit note, and the diagnosis needs to be specifically documented. In the note, the physician does not need to assign the actual code, but they do need to at least state it in words. For example, the physician doesn’t need to assign C79.51 (Secondary malignant neoplasm of bone), but the documentation should certainly state that the patient’s diagnosis is a secondary malignant neoplasm of bone.

All office visit notes need to be able to stand alone. If an auditor or an attorney or another clinician were looking at that document, they should be able to tell just by looking at that note what the patient’s diagnosis was.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC