Ob-Gyn Coding Alert

Question: I have a doctor that wants to see in writing where they have to document anywhere in their note, other than the diagnosis code they chose, the specificity of a condition. The issue in argument is for hyperlipidemia. They feel as long as her HPI indicates patient has hyperlipidemia and they pick the specific diagnosis code of mixed, that is enough. They said we are making this up, or it has been passed on like an old wives’ tale. Now they are making me doubt myself. They want it in writing. Nothing that I say or that anyone can say will sway them. What should I do?

Connecticut Subscriber

Answer: The ICD-10 guidelines address specificity. You can lead her but not make her comply. Per the introduction: “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized.

Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

Strategy: So if the physician doesn’t comply and the notes don’t support the diagnosis code, you should report an unspecified one. Keep track of denials to show the provider at a later time.