Wiki Diagnosis coding

[paula f3]

I code for an ASC, just recently had charts reviewed from an outside company and they are informing me that I have coded my cataracts incorrectly. I was under the impression that since we have the entire medical record which includes the H&P that i could code the diagnosis off the H&P. For instance the physician on his op report list cataract, while his H&P lists cataract, Nuclear Sclerosis. Is it appropriate , acceptable for me to code it this 366.16 or should I code 366.9? How will RAC see this on an audit perspective?

Thank you for your help
Paula

 

[kevbshields]

Don't view this as a "correction" of your work, so much as a documentation improvement opportunity. Encourage the providers to reflect the most accurate and specific post-operative diagnosis. In that way, regardless of what your H&Ps indicate, you always have the most specific and definitive diagnosis available on the operative report.

As for how external auditors view this, that would very much depend on the specific auditor, his/her background and training. Truthfully, in the OP setting, coders should use the "stand-alone" documentation model . . . but, every work setting is unique.

Good luck to you.

 

[paula f3]

Kevin,
Thank you for your response. I will take this as an opportunity to educate the physician as when he sends the surgery order he gives the dx as Nuclear Sclerosis, yet when dictating he give dx as cataract, just need him to be more specific.

Paula