Wiki Changing a code

[SBland23]

Our system is setup to when the provider sees the patient and selects the diagnosis it also puts the icd 10 code along side it. Ex if a patient was seen for an ovarian cyst the provider choose unspecified ovarian cyst (N83.209).


Our system also allows the provider to free text on the chart so they could put a note under that code. Example: Unspecified Ovarian cyst (N83.209)
Note: right side


If they put this in the office visit and sign off, how would you code this? Do you code the unspecified since they choose to put that code in the note or would you code right side ovarian cyst and change the code to the correct one?


Thanks in advance!!

 

[nisha70]

I code to the highest level of specificity. My providers select incorrect codes all the time because they are not coders, and are not aware of coding guidelines. As long as my provider documents the correct dx in the chart, I change and select the correct code.

 

[csperoni]

I agree 100%. As long as the information is documented, I don't care if the physician selected the easiest code to find. I run into this all the time with abnormal PAP, CIN, VAIN, VIN, hyperplasia. If the physician chose unspecified abnormal PAP because that appeared at the top of his list, but note indicates LGSIL cervical PAP, I am using the correct code.
NOTE: if you work for a large company, they may require the physician or a certified coder to make this change, but that would be an internal company policy. As long as it's documented, anyone can code it.

 

[mk2001]

A lot of my time is spent correcting their ICD 10 choice to match the specifics of their diagnosis.

 

[mitchellde]

I never look at the codes assigned by the providers. I read the note and code what the note indicates.

 

[cgaston]

I never look at the codes assigned by the providers. I read the note and code what the note indicates.

IMHO this is best practice, since the note is going to have to stand on it's own if it is ever audited.

 

[kdlberg]

It's been my experience that providers just select the first code that pops up, even though there are better choices. I think the last project I worked on, every single ortho code was unspecified side. But if the chart note said "left side," I coded left side.

Then there was the one who had diabetic patients with complications, and just kept picking E11.9. (Even for type 1.) So much fun redoing all of his charts for the whole MONTH.

 

[mitchellde]

Use the radiology interpretation if you have it at the time of coding.. a physician render this report so you are allowed to use it for coding.

 

[mitchellde]

I am not certain what you are saying. The laterality needs to be either in the radiology report or the attending provider note. otherwise you should query the provider for the laterality.