Wiki Coding Guidelines I.A.19

[momo2]

Does anyone know of a coding clinic that addresses Coding Guideline I.A.19 which states "The assignment of a dx code is based on the provider's diagnostic statement that the condition exists. The provider's statement that the patient has a particular condtion is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis".

I believe there has been much discussion surrounding this guideline and I'm trying to find out any information that if a diagnosis doesn't contain support, to me, negates this guideline.

Any thoughts are appreciated.

 

[ivorytofu@hotmail.com]

Hi momo2! At times it can seem that the GL's are contradictory or confusing. But the GL's must be taken as a whole and not compartmentalized. What this GL is stating is that if a provider diagnosis Strep throat and the Strep test is negative, the pt has Strep throat and Strep Throat is coded. You should be able to find evidence of this in the providers PE. Another example would be no testing was performed during the visit but the provider diagnosed the pt with x,y,z. The providers statement that the condition exists is sufficient to code the condition(s). Diagnostic testing does not have to support the providers diagnosis. Clinical Criteria definition: rules or standards on which a decision or judgment is made to determine medical necessity. The provider may discuss in his/her MDM the "clinical criteria" that was used to determine the pt's diagnosis and/or to rule out DDX but the final diagnosis is simply based on the providers diagnostic statement that the condition exists. Now, how does this work with other GL's, especially when providers like to document diagnosis with the word "other" in the description. The provider diagnoses Other specified disorders of nose and nasal sinuses, J34.89. But there is no documentation of what the "other" is and the GL's for "other" state: "Other" codes are for use when the information in the medical record provides detail for which a specific code does not exist." The pt has a disorder of the nose and nasal sinuses but the provider has not documented exactly what that disorder is you would choose J34.9 over J34.89 since the documentation does not support the coding and reporting of "other". You have not changed or diagnosed a new condition you are simply following both GL's. On the other had if the provider states the pt has "blue nose syndrome" (this is just an example of how to apply these two GL's), the documentation then supports the coding and reporting of J34.89 because there is no index entry for this term and the provider has definitively stated the "other" condition.