Andi L asked:
I am a relatively new profee coder for a large multispecialty clinic. My question is can you look at other physicians notes to assign a diagnosis for a different physicians encounter? For example; a patient with breast cancer is getting a port placed by one of our general surgeons. In the op report pre- and postop diagnosis the surgeon only states "breast cancer" In this case would you assign the unspecified breast cancer code or is it acceptable to go into the oncologists record and find the more specific diagnosis and assign that? Can you please give a reference for your answer? My belief was that I can only assign my diagnosis based on what I am given by that physician for that encounter; but I want to do things correctly.
Also; we get a lot of gastroenterology reports (upper and lower scopes) that do not really have enough specific information to support medical necessity. Is it acceptable to look at the GI docs consult note to glean more information on why the scope is being done and code from that? Example; pre- and post diagnosis may just state anemia or abdominal pain; but the consult note would give more specific information; such as the upper abdominal pain or fecal occult positive.
Thank you for any information/references you can provide. The hard part of going from school to real world coding for me are the gray areas. http://www.hcpro.com/HOM-306284-5728/Coding-Clinic-reiterates-guidelines-for-provider-documentation.html
Answer:
Coding Clinic states that "code assignment may be based on other physicians (i.e.; consultants; residents; anesthesiologist; etc.); providing that there is no conflicting information from the attending; in which case the attending physicians documentation supersedes all others.
Documentation in the medical record by any physician that is directly involved in the care and treatment of a patient can be used for code assignment. Whether a residents documentation needs to be co-signed by the attending is a situation best addressed by the hospitals internal policies; medical staff bylaws; and/or other applicable local/state/ federal regulations."
The Official Guidelines for Coding and Reporting define provider as "the individual legally accountable for establishing a diagnosis." If a provider is considered legally accountable for establishing a diagnosis within the regulation governing the provider and the facility; then his or her documentation can be used for code assignment and to report a new diagnosis. This would include nurse practitioners and physician assistants documentation in the health record.
Visit the hcpro.com website.
<http://www.hcpro.com/HOM-306284-5728/Coding-Clinic-reiterates-guidelines-for-provider-documentation.html>
I am a relatively new profee coder for a large multispecialty clinic. My question is can you look at other physicians notes to assign a diagnosis for a different physicians encounter? For example; a patient with breast cancer is getting a port placed by one of our general surgeons. In the op report pre- and postop diagnosis the surgeon only states "breast cancer" In this case would you assign the unspecified breast cancer code or is it acceptable to go into the oncologists record and find the more specific diagnosis and assign that? Can you please give a reference for your answer? My belief was that I can only assign my diagnosis based on what I am given by that physician for that encounter; but I want to do things correctly.
Also; we get a lot of gastroenterology reports (upper and lower scopes) that do not really have enough specific information to support medical necessity. Is it acceptable to look at the GI docs consult note to glean more information on why the scope is being done and code from that? Example; pre- and post diagnosis may just state anemia or abdominal pain; but the consult note would give more specific information; such as the upper abdominal pain or fecal occult positive.
Thank you for any information/references you can provide. The hard part of going from school to real world coding for me are the gray areas. http://www.hcpro.com/HOM-306284-5728/Coding-Clinic-reiterates-guidelines-for-provider-documentation.html
Answer:
Coding Clinic states that "code assignment may be based on other physicians (i.e.; consultants; residents; anesthesiologist; etc.); providing that there is no conflicting information from the attending; in which case the attending physicians documentation supersedes all others.
Documentation in the medical record by any physician that is directly involved in the care and treatment of a patient can be used for code assignment. Whether a residents documentation needs to be co-signed by the attending is a situation best addressed by the hospitals internal policies; medical staff bylaws; and/or other applicable local/state/ federal regulations."
The Official Guidelines for Coding and Reporting define provider as "the individual legally accountable for establishing a diagnosis." If a provider is considered legally accountable for establishing a diagnosis within the regulation governing the provider and the facility; then his or her documentation can be used for code assignment and to report a new diagnosis. This would include nurse practitioners and physician assistants documentation in the health record.
Visit the hcpro.com website.
<http://www.hcpro.com/HOM-306284-5728/Coding-Clinic-reiterates-guidelines-for-provider-documentation.html>
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