Wiki Adding diagnosis codes after the patient is seen that did not exist at time of encounter

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shihtzuaddict71

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I am having a back and forth with one of my providers. He is stating that is ok for him to go back and add diagnosis codes to E/M visits AFTER the patient has left, and for diagnosis that were not present at the time of encounter. Example- Doctor sends patient for an A1C, and the results come back later (same day, different day, etc) that the patient is diabetic. The provider wants to go back, add an addendum about the test results and then add that diagnosis to the enounter. I say no, because we should only be coding off of signs/symptoms since the definite diagnosis did not exist at the time the patient was seen.

Has anyone run into this? Do you have anything in writing that supports either yes or no?
 
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There are specific situations in which you may need to actually wait for results in order to accurately code. This happens rather frequently in dermatology when determining whether a removed lesion is benign or malignant.
In your situation, it would be wrong for the CODER (without physician update to change the diagnosis code. I do not see a definitive problem with the physician updating the records with additional information. From a logistics standpoint however, this raises some additional questions for me.
Are all encounters that include testing held until results come back?
- If so, you are delaying billing unnecessarily. The level of service cannot change based on results on another day.
- If not, then what difference does it make if the provider is changing coding that does not go anywhere.
I do not have any official guidance that states a provider may not amend records, only that a coder may not assign a code unless it has been documented by the clinician.
My personal opinion is - Why would you do this? It creates a lot of potential for confusion. Unless you have contracts that pay based on ICD10 codes, billing 99213 with dx of urinary frequency results in same payment as 99213 billed with dx of DMII.
The only time I would wait for results is when the CPT would change based on a result (like benign vs malignant lesion).
 
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These are claims that are not being held. They have been billed. This is to add HCC codes that would not be identified until the testing is done. I am not in agreement with adding a diagnosis that did not exist at the time of encounter. I feel it should be addressed and captured in next visit. Example, an A1C comes back that patient is diabetic.
 
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