# Diagnosis Coding Guidelines



## susanl3e (Mar 24, 2014)

What is the diagnosis coding guidelines for a coder vs a provider?
I.E.
Provider documents a diagnosis in CC, HPI, ROS but not in Physical Exam
in this providers Diagnosis codes, they have the diagnosis listed but there were no documentations in the Physical Exam.

IF a provider didn't provider diagnosis codes and a coder had to code the document, how will they be able to code the encounter if the diagnosis was mentioned in CC, HPI, ROS only. 

What is the guideline to coding a document when it comes to a coder vs. a provider?

I hope this makes sense. thanks.


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## Pam Brooks (Mar 25, 2014)

Providers shouldn't be putting diagnosis 'codes' in their documentation.  A coder should be abstracting the most appropriate and specific code based on the providers written description of the condition.  

Although it's important to link the chief complaint, the HPI, ROS, Exam, A&P throughout the note with respect to the condition(s) being evaluated, your job is to read through that and determine the most appropriate code.  So if the HPI indicates 'sore throat', the exam shows redness/exudate and the quick strep is positive, you'd code strep.

The provider gives you the information and the coder determines the code.

If your provider is giving you a diagnosis code, you may want to ask them to stop.


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## mitchellde (Mar 25, 2014)

Pam Brooks said:


> Providers shouldn't be putting diagnosis 'codes' in their documentation.  A coder should be abstracting the most appropriate and specific code based on the providers written description of the condition.
> 
> Although it's important to link the chief complaint, the HPI, ROS, Exam, A&P throughout the note with respect to the condition(s) being evaluated, your job is to read through that and determine the most appropriate code.  So if the HPI indicates 'sore throat', the exam shows redness/exudate and the quick strep is positive, you'd code strep.
> 
> ...


I so agree with you!!  However some EHRs do not allow the provider to sign off the note until a code is appended.  I say make the vendor turn that function off.  I agree with Pam, before ICD-10 CM gets here you may want to discuss this.


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## susanl3e (Mar 28, 2014)

Thanks Ladies,
We are auditing provider documentation and was questioning how they came to the conclusion of these diagnosis codes, I.E.
CC: Leg pain
HPI: mentions that patient complains of leg pain
ROS: Leg pain documented there
Exam: Leg pain not documented, provider states everything was normal.

As mitchellde mentioned about the EHR systems, providers are forced to select a diagnosis code within the EMR. A lot our clients do not have coders so the coder is the provider themselves.


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## mitchellde (Mar 28, 2014)

Sounds like he may be using a check box type of templet.  My suggestion/solution is that this note has no codeable dx.  It should go back to the provider for clarification.


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## polycoder (Mar 28, 2014)

I would code leg pain.


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## MsGarner69 (Mar 28, 2014)

polycoder said:


> I would code leg pain.



That's what I was thinking...until I got to the exam portion. I would query him and ask for clarification. This documentation example looks rather "lazy" (couldn't think of a better term) to me. Is this a typical problem with physicians?


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## susanl3e (Mar 28, 2014)

MsGarner69 said:


> That's what I was thinking...until I got to the exam portion. I would query him and ask for clarification. This documentation example looks rather "lazy" (couldn't think of a better term) to me. Is this a typical problem with physicians?



MsGarner69,
I agree. and yes this is a typical problem with physicians, most physicians that I've come across has terrible documentation, it is hard to even code their document due to the documentation.


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## MsGarner69 (Mar 28, 2014)

slee_iit said:


> MsGarner69,
> I agree. and yes this is a typical problem with physicians, most physicians that I've come across has terrible documentation, it is hard to even code their document due to the documentation.



so who's job is it to instruct physicians on the proper way to document (and enforce it) to make coding easier on us? I look at this as a team effort, where we all work together to insure that proper documentation and coding work together for the purpose of proper reimbursement. Why wouldn't everyone _want_ to be on the same page with insuring that is done on their prospective ends...especially physicians?


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## susanl3e (Mar 31, 2014)

MsGarner69 said:


> so who's job is it to instruct physicians on the proper way to document (and enforce it) to make coding easier on us? I look at this as a team effort, where we all work together to insure that proper documentation and coding work together for the purpose of proper reimbursement. Why wouldn't everyone _want_ to be on the same page with insuring that is done on their prospective ends...especially physicians?



That's where we come in. We have to insure the physicians are properly documenting the medical records so it will be easier to code.


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