Ob-Gyn Coding Alert

Be aggressive with your procedure/diagnosis queries for the sake of clarity.

In diagnosis coding, transforming medical records into a numeric code for billing purposes may not be enough. Documentation is the basis for coding. Thus, you should take into consideration accurate documentation as critical to diagnosis coding.

Risk: Deficient documentation could result in a payer's refusal to reimburse for a test or service you rendered. Make sure you and your physician speak the same language, so you can code at the highest level of specificity. Here are two tips to do just that.

Tip 1: Ensure Clarity Between You And Your Ob-Gyn

You should avoid 'ultraconservatism' in coding. Over the years, many coders have learned to break off from the practice of questioning the physicians when the documentation was not complete or was not clear to them. You and your physician should work hand in hand on going after better documentation -- as aggressively as you can.

While physicians do not look at a patient's medical record from the perspective of how it will be coded, you -- as the coder -- should.

"It is a difficult transition to get physicians to understand about what they have to put in a record for accurate coding versus what they need clinically. I think that is a real educational issue for them," says Carol Paret, chief community benefits officer, Memorial Hermann Healthcare System in Houston, Texas, during the 2002 Straight Talk series of group discussions on key issues in healthcare. This issue is still very much a valid one in today's circumstances. You and your physician should make it a point to bridge the gap between the physician language (the clinical language you read in the documentation), and the methodology you use as a coder.

Narrative terms may be required to support key procedures and diagnoses. For instance, a patient may have left lower quadrant abdominal pain (789.04), but simply stating or documenting "pelvic pain" (625.9) may not be specific enough to capture and reflect the severity of the patient's condition. Situations like this should prompt you query the physician (verbal or written) regarding the specific degree or type of pain that the patient may have.

Tip 2: Don't Expect Somebody to Do Coding For You

The task of appropriately documenting the medical record should fall on the physician's shoulders. You, as coders, cannot just pluck out information from undocumented sources to support your codes. Any information on a procedure or diagnosis that you have to bill must be confirmed and documented by the physician (or a certified healthcare provider), not anyone else.

Aim for this: A good medical record will contain information about the reasons a patient sought the physician's help, relevant medical history, diagnostic test results, findings, medical assessment of clinical impression and diagnosis, and the plan of treatment.