Wiki Diagnosis listed out numerically in reports

[az2tn@yahoo.com]

Hi all,
When a DX that is listed out numerically contradicts the description of the DX what do you do? I have "chest pain 786.59" on a chart however when you code out chest pain it codes to 786.50-unspecified. And nowhere in the op report does it state that the pt's chest pain is non cardiac to make it 786.59. The only indication that it is is the: 786.59. How do you handle this situation?

 

[jessv1910]

Who documented the code 786.59? Remember that you can only code from Physician documentation. Physicians are not coders and even though sometimes they might know the codes they need to write the diagnosis. We coders, have to review the entire record and code accordinly. You can always query the physician and ask for a clarification and to specify the "Chest Pain" dx.
Maybe this will help you:
According to AHA Coding Clinic for ICD-9-CM 1st Quarter 2012, page 6:
“It is not appropriate for physicians to assign a code number in place of a written diagnostic statement. ICD-9-CM is a statistical classification, per se, not a diagnosis…. It is the provider's responsibility to provide clear and legible documentation of a diagnostic statement, which is then translated to a code (by a coding professional) for external reporting purposes.”

 

[az2tn@yahoo.com]

It is a dictated op report by the physician. Thank you so much for finding that coding clinic. That really helped answer my question.

 

[jessv1910]

You are welcome!