# Help with medicare guidelines



## 1formissy (Oct 26, 2015)

I am attempting to find something in writing from Medicare in regards to diagnosis coding off the documentation. 

Example. A provider's record does not document the sign/symptom nor diagnosis(s) of the patient. Only what was performed. It has been my understanding that on an audit perspective, you cannot code that charge because there is no diagnosis to that particular record. 

The coder is pulling a diagnosis from the EMR to code that case. I believe this is not allowed by CMS, but I am having a rough time trying to find that in writing. 

I read the False Claims Act, but really nothing in writing I can find that says just what I mentioned. I have to present that information to the provider. 

Any help would be most appreciated!!


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## fill.ess1@gmail.com (Nov 5, 2015)

*no dx for chart*

perhaps this could be coded as annual physical-- the 9983x-thru 9993x codes.
you're not actively treating a medical condition, so you would use a Z code   for example  z00.00 with 99385 or 99396


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## 1formissy (Nov 6, 2015)

fill.ess1@gmail.com said:


> perhaps this could be coded as annual physical-- the 9983x-thru 9993x codes.
> you're not actively treating a medical condition, so you would use a Z code   for example  z00.00 with 99385 or 99396



Thank you for your response, however, this question has nothing to do with physicals.


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## mitchellde (Nov 6, 2015)

If you look in the E&M guidelines for either the 95 or 97 it states a chief complaint must be documented.  Also for medical decision making diagnosis and complexity of information are two of the components of MDM you must have at least one or both of these documented.  If no diagnosis or symptoms are indicated in the chart note then can I ask what was documented?  The coder is not allowed to extract a diagnosis from previous encounters within the EMR.  Each note must state on its own.  Without all the necessary elements then there can be no encounter billed.


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## karen.benson (Nov 18, 2015)

*diagnosis coding from a previous note- yes or no?*

i am also looking for documentation for coding from previous notes. 
 i was told you CAN NOT do this and a co worker says she was told you CAN.
i do not feel comfortable doing this as i do not think this would hold up in an audit.  
has anyone found this documentation anywhere??
it must be somewhere


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## suemt (Dec 7, 2015)

I often get these kinds of questions and they are hard to answer because someone expects you to find an explicit answer.  

As Debra stated, it is a given that the note would explain why the patient presented, or what the provider looked for, or what the provider found, or what the provider prescribed as treatment.  And you want to scratch your head and say, does nothing in the note give any clue about why the patient was there or what the provider did?  

That is where you would get your diagnosis.  

Unless you are saying the note was so skimpy to say "Patient is here for followup, and everything is cool.  Have them come back next month".  

In which case, you cannot harvest a Dx from another service and the documentation does not support the service that was likely billed.  

If I were arguing in an audit on behalf of a provider, it could be a STRETCH that on an exception basis you could infer some information from a prior note to pertain to the current visit if there were some sort of references to the prior visit or note, but it would be a long shot and could not be guaranteed to fly.  

I'm interested to hear how this turned out.


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## mhstrauss (Dec 8, 2015)

Just my thoughts...but the first time I read the OP, I was under the impression that this question was referring to an office procedure, such as an injection (based on the statement "only what was performed"). So if a provider documents, dosage, route, etc specifically for the injection, but not why he's injecting, Would that hold up in an audit. I certainly could be wrong. IF that is question, here's a great article from MGMA, which does state that medical necessity must be documented in the procedure note. There are Medicare references included.

http://www.mgma.com/Libraries/Asset...n-documentation-MGMA-Connexion-April-2010.pdf

HTH some!


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## LisaAlonso23 (Jan 29, 2016)

I'm facing a similar issue and am in need of reliable, legitimate references regarding compliant documentation & the handling of it. I would personally feel more comfortable it there was specific documentation outlining the how & why providers need to document procedures, particularly for anesthesia. Then, take it one step further outlining exactly what we can code from. It's great to have the guidelines for E/M, but we need guidelines for providers for procedures as well. If this was on the CMS website somewhere, that would help resolve a lot of misunderstandings and provide us with a leg to stand on when facing documentation issues. If this is located somewhere & I missed it, please let me know. Best of luck to you.


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## ValerieBatesHoffCPCCPMA (Mar 14, 2016)

*Medicare Claims Processing Manual  Chapter 23 -Fee Schedule Administration and Coding*



1formissy said:


> I am attempting to find something in writing from Medicare in regards to diagnosis coding off the documentation.
> 
> Example. A provider's record does not document the sign/symptom nor diagnosis(s) of the patient. Only what was performed. It has been my understanding that on an audit perspective, you cannot code that charge because there is no diagnosis to that particular record.
> 
> ...


*
Complying With Medical Record Documentation Requirements*

*Insufficient Documentation Errors*
Claims are determined to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed (that is, the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary). Claims are
also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety. 
Insufficient documentation errors identifiedby the CERT RC may include:
*
Incomplete progress notes (for example, unsigned, undated, insufficient detail);*

 Unauthenticated medical records (for example, no provider signature, no supervising signature, illegible signatures
without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures); and 

No documentation of intent to order services and procedures (for example, incomplete or missing signed order or progress note describing intent for services to be provided).

https://www.cms.gov/Outreach-and-Ed...wnloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

*Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements*

10.3 - Outpatient Claim Diagnosis Reporting
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be
chiefly responsible for the outpatient services. For instance, if a patient is seen on an
outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive
diagnosis is not made, the symptom is reported. If, during the course of the outpatient
evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the
definitive diagnosis is reported. If the patient arrives at the hospital for examination or
testing without a referring diagnosis and cannot provide a complaint, symptom, or
diagnosis, the hospital reports the encounter code that most accurately reflects the reason
for the encounter.

10.5 - Coding for Outpatient Services and Physician Offices
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
The Official ICD-10-CM Coding Guidelines include a section for Outpatient Services
(hospital-based and physician office). These guidelines can be found in the annual updates
to ICD-10-CM posted at http://www.cms.gov/Medicare/Coding/ICD10/index.html
Contractors, physicians, hospitals, and other health care providers must comply with the
Official ICD-10-CM Coding Guidelines.

10.6 - Relationship of Diagnosis Codes and Date of Service
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10,
Implementation: Upon Implementation of ICD-10)
Diagnosis codes must be reported based on the date of service (including, when applicable,
the date of discharge) on the claim and not the date the claim is prepared or received.
Medicare contractors are required to edit claims on this basis, including providing for
annual updates each October.
Shared systems must maintain date parameters for diagnosis editing. Use of actual
effective and end dates is required when new diagnosis codes are issued or current codes
become obsolete with the annual updates.

The Health Insurance Portability and Accountability Act (HIPAA) requires that medical
code sets must be date-of-service compliant. 

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf


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