Ob-Gyn Coding Alert

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

Connecticut Subscriber

Answer: The ICD-10 guidelines address specificity. But 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.