Medicare Compliance & Reimbursement

Rely on physician's notes when selecting Dx codes.

Incomplete documentation greatly damages coders' ability to submit accurate ICD-9 codes on their insurance claims.

If the ED physician fails to indicate the diagnosis that he treated, you may be able to deduce what diagnosis codes apply by carefully reading through his documentation. Check out these tips you may be able to use to deduce the proper ICD-9 code on some op reports.

Open The Notes--Even When You Don't Have To

Suppose your physician hands you a chart with the procedures noted and the diagnosis written as "rule out fracture." You can tell by the x-rays ordered and obtained that the body area in question is the left forearm. But because you may not report "rule out" diagnoses to insurers, the phrase "rule out fracture" gives you no more useable information than a chart without any diagnosis at all.

You could ask the physician which diagnosis to report, or you could examine the documentation yourself. "If your group has a policy that includes 'coding by abstraction' by certified/qualified coders, then submitting charges based on what is supported (documented) in the note is appropriate," says Ellie Sclocchini, CPC, consultant with Physician Reimbursement and Compliance Specialists in Mullica Hill, N.J. "The physician should be signing off on these charges as part of your internal policy."

Keep in mind, you should never code by "assumption"; instead, follow established guidelines. Some EDs choose to review the documentation and compare it against any diagnoses recorded in the chart, even when they aren't required to. This ensures that the documentation matches the code selection every time.

"I know it is more work, but I always check the chart note, and I usually bill the problems listed in the note," says Louise Glynn, office manager at Riverbend Medicine in Fuquay-Varina, N.C. "We are on an electronic medical record (EMR) system, so it is easier than reviewing paper charts, because with EMR the physician selects the code and the note is very specific."

Unearth Codes Buried In Documentation

Getting back to our example above, you read through the dictation in the "rule out fracture" chart and you find this is "an 11-year-old girl who was riding piggyback when she fell on her left arm. She had immediate onset of pain, and she has continued to complain of pain. A detailed exam is documented, and x-rays are ordered and interpreted as 'AP and lateral of the left forearm are negative for acute bony abnormality.' "

The physician notes that "the mother was told that occult fractures can occur in children and you cannot be 100 percent sure that no fracture is present, but the exam and x-ray seem to indicate that there is no fracture."

He then gives his impression as "Contusion of the forearm," so you know not to use a fracture diagnosis for this encounter. Instead, you should report 923.10 (Contusion of upper limb; forearm) as the correct code assignment for this visit.

Check with physician when in doubt: If you are new to coding diagnoses from the physician's notes, you should double-check your code selections with the doctors until you feel comfortable that you are choosing the right codes. This action may depend on the amount of detail that your physicians document in their notes or the variety of conditions that your practice evaluates.

Tip: Make sure your ED creates a policy in writing that spells out what you should do when no diagnosis is listed. Some physicians prefer that you ask them for information, while most others rely on their coders to select an accurate code.