# PA documentation trumps MD?



## Coder Bradley (May 28, 2010)

A patient came into the ER, evaluated and treated by the PA.
Patient had a CT scan, read by a MD.

MD documented an absence of the left kidney, PA documented congenital atrophied left kidney.

Per my supervisor I should code the atrophied kidney and NOT the absence of the same kidney, because the PA was the one that evaluated and treated the patient, not the MD?

Is this accurate or should only the absence of the kidney be coded?


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## sbicknell (May 28, 2010)

A radiologosit should be doing the final read on the CT. See what the final report says.

But regardless, the PA did the face-to-face encounter with the patient independent from the MD, so you code the E&M encounter based on the PA's assessment and findings. 

If it turns out the Radiologist's report supports the MD's review, then the PA can make an addendum to her documentation. And whoever sees the patient for f/up will have the PA's addendum and the Radiologist's report to correctly code the f/up encounter


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## Coder Bradley (Jun 1, 2010)

The MD was the one that did the final report and documented the absence of the kidney.

I'm wondering if V45.73 should be reported in place or in addition to 753.0


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## sbicknell (Jun 2, 2010)

Maybe we are just using terms differently. 

An MD can look and state what his findings are in order to treat his patient. But a Radiologist must provide the final written interp of the xray. Unless your MD is also credentialed as a Radiologist, his "interp" is irrelevant

Either way, your PA was the only one face-to-face with the patient and the encounter is coded based on her exam, eval and MDM

Now I'll throw my 2 cents in.... you are a CPC-A meaning you are in a learning-mode. If you have questions on guidance your supervisior has provided, you should be discussing these with her and not double checking or questioning her guidance in this forum


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## Coder Bradley (Jun 3, 2010)

When my supervisor makes herself available for such a discussion I will happily do such, however most of my contact with her is through post it notes stating that I did it wrong and to do it her way.

Thank you for your time in replying.


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## sbicknell (Jun 3, 2010)

Elbereth

My apologies for my 2-cents. Also, sorry to hear you are working with such a lack of support from your Supv. There is no opportunity to learn with "don't do xxx, do zzz" without an explanation or discussion. Hopefully you have an experienced coder at your site that is more available to you.


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## RebeccaWoodward* (Jun 4, 2010)

Elbereth,

I would encourage you to continue to post your questions here, also.  There are many seasoned coders in this forum that will happily assist you with questions.  As seasoned, older coders, it is our responsibility to take the younger coders under our wings and support them, guide them and supply them with proper coding information.  This should be a safe place to post questions and debate them openly.  Personally, I have worked with managers (former) that were completely ignorant of coding guidelines, Medicare regs, etc.  Were they at fault?  Not necessarily. Sometimes, their skills lie elsewhere.  This is why we must ask questions when in doubt, gather information, present the information/facts and have a healthy debate.  

Best of luck~


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## mitchellde (Jun 4, 2010)

I am in agreement with Rebecca.  This is the best place for open debate.  I too hav eworked in places where the supervisor was only looking for the easy way to get it done and there was no place like this available to question things.  Please continue to ask away.


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## Coder Bradley (Jun 4, 2010)

There is no need to apologize for your 2 cents, I agree completely.  ^^

If there are any suggestions as to websites that I can look things like that up it would be very helpful, I don't have a lot of luck asking my coworkers about things like this since I seem to be the only coder here.


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## sbicknell (Jun 4, 2010)

Unresponsive supv and no other on-site coders to discuss with. Boy, you are working in a black hole. Then this forum is probably your best bet for feedback. I'm not sure where you are located or what specialty you are working but here are some suggestions

--Sign-up for your Medicare payers webinars/conference call programs. They are free, topics vary and they earn CEUs
--Make contact with a coder at another practice that is same specialty to you
--See if there is a local AAPC chapter where you can establish some contacts
--Part B used to have a list serve that you could register and participate and post questions (I have lost touch with that but someone may be able to give you the current link and info)
--can also just do an internet search for what you need (ie MD vs PA documentation) and you get a lot of links and sites that this question has been asked/discussed


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## RebeccaWoodward* (Jun 4, 2010)

Here's the Part B list serve.

You can subsribe for free by selecting the "subscribe" tab next to Medicare Part B.

http://www.decisionhealth.com/Communities/physiciansDisc.aspx

There may be other list serves of interest to you, also.


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## LLovett (Jun 4, 2010)

*Missing the forrest for the trees I think...*

This is not a coding issue at all in my opinion. This is a quality of care issue. This needs to be taken to the quality or risk management department, the patient record needs to be corrected to reflect what is actually present or not, then you will know what you can or can't code.

Good luck

Laura, CPC, CPMA, CEMC


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## sbicknell (Jun 4, 2010)

I agree but that wasn't the question.

Regardless of the outcome of the review, the MD can not change the documentation by the PA and change her DX. The MD was not there with the patient.

The MD can (as I suggested) add an addendum to the chart. But regardless of what the MD saw on the films or what the PA concluded on exam, the Radiologist's final report over-rides them both.

I still stand by that the PA must document and code based on her own assessment. The MD has recourse options of his own he can take. And if there is question to the Rad final report, then a 2nd read by another Rad can be done. 

In the end, after everyone involved has hashed it out and the the smoke settles, a report can be added to the chart if the PA assessment is proven incorrect. If so, then I would re-code the encounter in the system and refile with the correct DX codes to the payer. Not for payment but so that the "big system in the sky" has the correct conditions for this patient.


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## Coder Bradley (Jun 4, 2010)

Thank you all very much for your input!


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