nyyankees
True Blue
If the doc has diagnosis codes 719.46 and 719.45 (knee + hip pain) on the claim BUT in his assessment it states patient has torn meniscus can claim be released?
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Wiki Diagnosis-If the doc has
- Thread starter nyyankees
- Start date
mitchellde
True Blue
In my opinion no, unless you change the code to match the note
nyyankees
True Blue
Thanks. I have always based my auditing on that the dx code (719.46) should be documented in the Plan and Assessment section of the note. Not in HPI or exam. Am I correct?
mitchellde
True Blue
The diagnosis code is based on the entire note. If the assessment states knee pain but the exam is torn meniscus then I code the torn meniscus, if the exam states knee pain ans the final assessment is torn meniscus then I code torn meniscus as the pain is a symptom of the definitive diagnosis. It must all hang together.
Example.. I had one note that stated CC-skin rash
the exam state no rashes or abnormalities and no concerns
the assessment said no issues but the plan indicated a cream for the rash.... WHAT RASH! this note went back to the provider.
The note must hold together not just one piece of it.
Example.. I had one note that stated CC-skin rash
the exam state no rashes or abnormalities and no concerns
the assessment said no issues but the plan indicated a cream for the rash.... WHAT RASH! this note went back to the provider.
The note must hold together not just one piece of it.