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MAKE A QUERY ON THE FOLLOWING
Here is what we know about the patient:
Most recent visit from Cindy's chart documented her diagnosis as Major Depressive Disorder(MDD). The patient called in and stated she needed a refill on her Abilify prescription. Patient was told she needed to come in to see the provider to discuss her medication. Patient scheduled an appointment and saw Dr. Payne regarding her depression and got her refill for Abilify. The MDD was mentioned in the past medical history section of the office visit note.
Things to think about: Just because the patient was diagnosed with Major Depressive Disorder previously and it is listed in the history section of the chart. does not mean we can just slap that diagnosis on the claim.
Yet patient was seen for her "depression" and to refill her medication.
Your Task: Create a query regarding the specificity of the diagnosis.
Why: Let's consider the diagnosis listed for the current visit along with the mention of a more specific diagnosis in the history section of the visit. Compare Depression, unspecified verses or in comparison to Major Depressive Disorder. First, Major Depressive Disorder can be a recurrent problem or a single episode. It can involve psychosis or psychotic features. It can also be linked to Bipolar Disorder or Manic Episodes. Or a patient can be in full remission from MDD. Given the multitude of variables, it is important to query Dr Payne for more specificity in regard to "depression".
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