Wiki Diagnosis codes

[stlbill511]

Can we only put the diagnosis codes that the doctor has in the Assessment or can we add a diagnosis as long as it is reflected in the doctors notes, maybe that he missed putting in the Assessment? I was told we could do this by several speakers at workshops, that our diagnosis codes do not necessarily have to match the doctors as long as it matches the doctors notes. Is this correct? We have hired an auditor to check our records and she is stating I have to only use what the doctor has down or suggest to him to make an addendum. I am now confused on who is correct?

For example, he may use the state the patient has carpal tunnel but has done no testing to prove that the patient has carpal tunnel. The notes dictate that the patient has numbness and tingling, so instead of billing out the carpal tunnel diagnosis, I bill out numbness and tingling or another example is that the doctor may miss something like the patient has a blood pressure reading that is high. The doctor may not put in that diagnosis code but puts it in the notes that the blood pressure reading was high today and usually in the Plan section tells the patient to followup with his PCP.

I want to make sure I am coding out the correct way, so any help in this matter is greatly appreciated.

Caroline
CPC

 

[mitchellde]

Yes you should code from the narrative note. The codes on the claim must be supported by the narrative. The codes on the claim do not need to be sported by the codes selected for the assessment. Coding clinics have stated that the numeric code should not even be in the medical record document. And that the provider is required to render the diagnosis in their own words. I am not sure what auditor you talked to but they are incorrect.