Wiki coding question

[lec121661]

good morning,

I just recieved an audit and was dinged on coding 623.5 with 112.1 togther can someone please give me guidance on if this is correct. the note states A/P candidasis vaginal medication was give along with vaginal discharge with a CT/GC RRNA done with a wet prep there was no result noted by the physician if it was postive for any bacteria. there is a result that was pasted into the note from the lab but the physican did not state that in her assessment

any help would be greatly appreciated or guidance as to if the two codes can be coded together.

thank you in advance
LaTanya

 

[OhioMB]

If you wait to do your billing until you know what the bacteria is then you would only bill the 112.1. You would need your physician to sign off on the results. If you're billing out before results are in then you should be just sending the 623.5 and your physician should have a notation stating they are pending lab results.

 

[lec121661]

that is what i said. the provider did not state in the note that it was positive for candidasis but they still marked in wrong. i need something concrete to show the auditor

 

[mitchellde]

If the provider did not state that it was positive for the organism then it cannot be coded. You cannot code from the posted result. Therefore the auditor is correct.

 

[lec121661]

If the provider did not state that it was positive for the organism then it cannot be coded. You cannot code from the posted result. Therefore the auditor is correct.

hello,

she marked it incorrect for me using the 623.5

 

[lec121661]

If the provider did not state that it was positive for the organism then it cannot be coded. You cannot code from the posted result. Therefore the auditor is correct.

Hi Debra,

So by me coding the 623.5 was incorrect is that what you are saying? but i thought the 112.1 is to show positive results. why would i code the 112.1 if it was not positive results? please advise

thanks
LaTanya Cross, CPC-CCS-P

 

[mitchellde]

623.5 is for leukorrhea not specified as infective, then you coded it with a 112.1 for the infection. If you have the definitive dx of the candidiasis then you would not code a condition not specified as infective they are contraindicated. You stated you coded them both but the provider did not document the organism. Therefore only the 623.5 should be coded.

 

[lec121661]

623.5 is for leukorrhea not specified as infective, then you coded it with a 112.1 for the infection. If you have the definitive dx of the candidiasis then you would not code a condition not specified as infective they are contraindicated. You stated you coded them both but the provider did not document the organism. Therefore only the 623.5 should be coded.

thank you,

I did code the 623.5 the provider did do a KOH prep but did not notate the findings in the assessment and plan. the lab was tied into the note per the dod guidelines you can not code from the lab unless the provider documents. but the auditor stated other wise that i should have coded just the 112.1 i was looking for clarification you help alot

thank you