Hi, I'm really hoping someone can give me some insight into diagnosis coding for hospitalists. I am new to auditing. My specialty is orthopedics, but my director has me auditing a Hospitalist coder. I am noticing that she is not coding all of the diagnoses under the Assessment and Plan. For example, the hospitalist documents 10 diagnosis codes, but my coder is only coding 7 of them. I have also noticed that the diagnoses she is Not coding will look like this -
9. Hypertension - continue metoprolol.
Where as the ones she Is coding will look like this -
1. Diabetes Mellitus type II - continue insulin, get an A1c
Basically, the diagnoses she is coding have some kind of further instruction or have a test ordered.
Any thoughts? Is my coder correct in Not coding all of the diagnoses. I do understand that the hospitalist Cannot code for a condition being followed in the hospital by another physician.
TIA
9. Hypertension - continue metoprolol.
Where as the ones she Is coding will look like this -
1. Diabetes Mellitus type II - continue insulin, get an A1c
Basically, the diagnoses she is coding have some kind of further instruction or have a test ordered.
Any thoughts? Is my coder correct in Not coding all of the diagnoses. I do understand that the hospitalist Cannot code for a condition being followed in the hospital by another physician.
TIA
diagnosis codes, diagnosis coding