I have a provider that is noting an extended HPI, and Comprehensive exam, then under Assessment and Plan, just stating the diagnosis with the ICD-10 code.

For example, if the doctor is seeing the patient for Sinusitis or dizziness the assessment states:

J32.2 Chronic Sinisitis

R42 dizziness

Sometimes there is nothing else, no notes, orders or expansion in the note anywhere.

Very occasionally there may be an order for an xray or MRI.

I’m not seeing a true assessment and plan, giving their findings on how they got to the diagnosis. There is a disagreement going on that noting the diagnosis that way should count for a point- because it’s noted. I feel like shouldn’t they expand on it in some fashion? Showing their medical decision making? Impressions to score the risk?

Anyone had a provider like this in the past at all and have suggestions?