Anesthesia Coding Alert

Question: Should a patient's diagnosis be coded to the highest level of specificity, or to match exactly the doctor's statement? During a pain management chart audit, I found a physician's statement that a patient's diagnosis was reflex sympathetic dystrophy (RSD). I would have coded it as 337.20 (RSD, unspecified), but his office coded it as 337.22 (RSD of the lower limb). The patient had leg pain and rotating of the ankle, but would that be clinically considered as RSD of the lower limb?

Michigan Subscriber  
Answer: Physicians often authorize experienced and credentialed coders to review the medical record and use additional information to help clarify diagnosis statements and select the most specific code. The goal is to code diagnoses and procedures to the highest specificity, so use any information you can obtain to help with that process. In the example you give, using the more specific code 337.22 would be appropriate if you have access to the patient's chart and it clearly specifies leg pain and ankle problems. If you don't have access to the chart and can't get more specific information, use 337.20.  
-- Reader Questions and You Be the Coder answered by Cecelia McWhorter, BA, CPC, a coder with the physician billing agency of Comp One Services, Ltd., in Oklahoma City; Gina Graham, CPC, an anesthesia coding specialist in Hephzibah, Ga.; LaSeille Willard, CPC, anesthesia coder for the physician group Anesthesia Consultants in Thurmont, Md.; Elaine May, coder with the physician group Anesthesia Consultants of Oxford in Oxford, Miss.; and B.J. Horton, coding manager with Central Kentucky Anesthesia in Lexington.