I code for a General Surgery practice and have received multiple denials regarding medical necessity for skin lesion removals. The problem is the provider is mentioning in their initial visit that the lesion is, for example, itching (which meets the LCD guidelines for their state), but does not mention any symptoms at all on the operative report done days or weeks later. My diagnosis codes are based on the actual date of service documentation and not prior notes so it is not coded on the procedure date of service. The pathology is read as a benign lesion and the claim gets denied.
I brought this up with one of my managers and she posted the question to a billing forum. She received a response that said you can code off of previous notes and cites CMS Transmittal AB-01-144 (ICD-9-CM Coding for Diagnostic Test), which states the following: "On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient?s medical record if it is available."
Does anyone else have any articles or websites to support the idea of coding diagnoses or conditions from a previous note? Is this just common sense knowledge that I have not been following? Thanks in advance for any advice!
I brought this up with one of my managers and she posted the question to a billing forum. She received a response that said you can code off of previous notes and cites CMS Transmittal AB-01-144 (ICD-9-CM Coding for Diagnostic Test), which states the following: "On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient?s medical record if it is available."
Does anyone else have any articles or websites to support the idea of coding diagnoses or conditions from a previous note? Is this just common sense knowledge that I have not been following? Thanks in advance for any advice!