Wiki Coding from another facilities medical records

[SSummCCH]

Hello,

I have a compliance question. Our CAH hospital has access to the adjacent clinic's medical records. This is not our clinic and is not owned by the hospital at all. Can our coders go out to their records to code for services received at our hospital. To clarify, a patient is sent to our facility for lab or x-ray. The provider provides a diagnosis code. But, the hospital's coder goes out to the clinic records to determine further diagnosis codes that are not on the order.
Can that coder do that? I was always under the impression a code cannot be added or changed or deleted unless the provider does so.

 

[thomas7331]

This is a tough question to answer without knowing more about your facility and its relationship with the other clinic. Generally speaking, if a physician has ordered a test or procedure that your facility is performing, then it's appropriate to use the particular record of that provider where the original decision to order the test was made if you need additional information or specificity for coding. Doing this is similar to making a query to the provider when additional information is needed, but by accessing the record directly you may be able to avoid taking up the physician's time since the information you need was already documented there.

But in my opinion, you have to be careful here because your coders should limit the information they're taking to just what is relevant and necessary to the encounter being coded - I don't think it would appropriate to be broadly accessing outside records to harvest diagnosis codes or look at information unrelated to the specific order for which information is needed. Your facility should create written guidelines for the coders that specifies in which situation they are allowed to do this, what records can be used, and also how far back they can go in the record. I also think that if these providers are not under the same organization as your facility, that it would be a good idea to make them aware that you're doing this and to get their consent - even though it's likely technically not a HIPAA requirement since you're coordinating care for the patient, the records do belong to someone else and ethically shouldn't be accessed without their knowledge.