Wiki Assuming what dr's mean

[SDAlward]

I work for a cardiology practice and it has come to our attention that medicare is not paying for stress ekg's with dx R07.9(chest pain unspecified), but will however pay for R07.2(precordial chest pain). Our doctors usually don't specify the type of chest pain, and just dictate "chest pain" which to me should be R07.9. After a meeting with one of the doctors, he told me that when they say chest pain they mean precordial pain. Wouldn't he have to dictate that if that's what he meant? I'm not comfortable with assuming and not having the appropriate dictation in case they request medical records. If anyone has a link I could show him that would help

 

[1073358]

dx

I don't have a link, but he needs to document what he means then. If the chart doesn't specify precordial, you can not code that.

 

[cfitzgibbons]

I work for a cardiology practice and it has come to our attention that medicare is not paying for stress ekg's with dx R07.9(chest pain unspecified), but will however pay for R07.2(precordial chest pain). Our doctors usually don't specify the type of chest pain, and just dictate "chest pain" which to me should be R07.9. After a meeting with one of the doctors, he told me that when they say chest pain they mean precordial pain. Wouldn't he have to dictate that if that's what he meant? I'm not comfortable with assuming and not having the appropriate dictation in case they request medical records. If anyone has a link I could show him that would help

In my training, it was emphasized that there is no assuming in coding. Code on what is documented.

Colleen Fitzgibbons B.A., C.P.C.