Wiki documentation on diagnotic procedures

Create Wiki
R

rykin7609

Networker
Messages
85
Location
Alvin, TX
Best answers
0
Morning,

I am looking for any written or documentation on the requirments for Diagnostic Procedures in Medical Records.

To be blunt, I have a physician who is not documenting in his reports that the procedure he is doing is diagnostic, even though I know it is, and he has stated that it is. I have to find written proof that the word diagnostic HAS to be in a procedure report for proper payment.

(or am I barking up the wrong tree? does anyone know for sure?)

:confused:
 
Diagnostic procedure

If the procedure being performed is diagnostic in nature and is documented in the medical record as diagnostic it is diagnostic. If a procedure that's diagnostic leads to an actual non diagnostic procedure...code the procedure.
 
rykin7600 said:
Morning,

I am looking for any written or documentation on the requirments for Diagnostic Procedures in Medical Records.

To be blunt, I have a physician who is not documenting in his reports that the procedure he is doing is diagnostic, even though I know it is, and he has stated that it is. I have to find written proof that the word diagnostic HAS to be in a procedure report for proper payment.

(or am I barking up the wrong tree? does anyone know for sure?)

:confused:
Click to expand...

I see your frustration...
but to clarify your saying, you know its diagnostic and he has verbally told you it is, but the dictation is not restating that it is diagnostic so you have no paper trail to prove that it is diagnostic....correct?
I have seen this in the past myself and too question how to resolve this. Not all Doctors dictate everything we coders need and they do not want to be told how to do there jobs.
:eek:
 
I know of no reference that states the provider must state a procedure is diagnostic,
I fail to see how this is relevant for coding . If the patient comes in for screening then the procedure is screening the note does not need to state this. whether a procedure is for diagnostic purposes or therapeutic purposes does not change how it is coded.
perhaps I am missing something in your query?
 
Yes and No,
I guess i should have asked what type of procedure the original poster is referring to. If you are doing an Intervention Vascular procedure there are allot of codes the require proper medical necessity documentation to support the codes given.
Such requirements regarding diagnostic vs theraputic are stated on page 387 in CPT
Sorry if i confused this...
 
I am still seeing no difference in the code used, as long as the documentation supports the code we do not need the word diagnostic or therapeutic documented, I have never had a provider document this and I have never not been able locate a code, whether it is interventional vascular or open surgical.
If it is screening, the reason for the procedure must be clearly documented but it does not have to be restated in the note that it is screening or diagnostic. I am still not seeing the problem, so I am still siding with the provider on this.
 
I am still seeing no difference in the code used, as long as the documentation supports the code we do not need the word diagnostic or therapeutic documented, I have never had a provider document this and I have never not been able locate a code, whether it is interventional vascular or open surgical.
If it is screening, the reason for the procedure must be clearly documented but it does not have to be restated in the note that it is screening or diagnostic. I am still not seeing the problem, so I am still siding with the provider on this.
 
Sorry, apparently I do not ask the correct questions.

Okay, The doctor comes in and does a diagnotic Left Heart Catherization, he then proceeds (or another interventionalist) to a PCI. The webinars I have been attending have clearly stated that the documentation must say it is a diagnostic procedure or just the PCI can be billed and we must basically "give away" the diagnostic Left Heart Catherization.

What I am looking for is written proof to take to the doctor saying if you did a diagnostic Left Heart Cath, then state it or it is "Fricken' Free"

All my other cardioligists are saying it's diagnostic in their documentation but this one and I need to have something to show him he must say this or well, free
 
For interventional procedures in order to unbundle diagnostic codes the interventionalist
must: (just remember every note stands for itself)

A prior study is availible, but as documented in the medical report

a. The patients condition with respect to the clinical indication has changed since the prior study
b. There is inadequate visualization of the anatomy/pathology
c. There is a clinical change during the procedure that reauires new evualtion outside the target area of intervention.

Same with a diagnostic mammogram - radiologists have to tell you they are doing a diganostic in the report with the reason as to why they are doing a diagnostic.

Also the examples that are in Dr.Z book the wording also says diagnostic angiogram was performed.

Erica Ross CIRCC, RCC
 
rykin7600 said:
Sorry, apparently I do not ask the correct questions.

Okay, The doctor comes in and does a diagnotic Left Heart Catherization, he then proceeds (or another interventionalist) to a PCI. The webinars I have been attending have clearly stated that the documentation must say it is a diagnostic procedure or just the PCI can be billed and we must basically "give away" the diagnostic Left Heart Catherization.

What I am looking for is written proof to take to the doctor saying if you did a diagnostic Left Heart Cath, then state it or it is "Fricken' Free"

All my other cardioligists are saying it's diagnostic in their documentation but this one and I need to have something to show him he must say this or well, free
Click to expand...



YES, Cardiology with their caths as well as vascular and their stenting procedures do require the documentation to state that it is diagnostic, every webinar i have sat in have stated that. Especially when the are doing more than what is bundled into allot of these bundled codes and that now fall into a hiarchy. Take a look into some of the stuff Dr. Z has written you may find what you need to bring to your providers in some of his publishings. Also try the ACR and/or SIR.
hope this helps.
 
This also goes with cardiology. On page 501 is says the exact same thing. Diagnostic angiography has to be documented in the report.

Hope this helps some.

erica Ross CIRCC, RCC
 
Always Sunny,

Thank you for the suggestions, I will look into the ACR and SIR. Have not recieved our new Dr. Z books yet so when they come I will check there too. If you come up with any more places to look I would greatly apreciate it. This doctor is kind of a stubborn sort and unless it is written and shoved in his face, he does what he wants.

Thank you for your feedback everyone!
 
Erica,

Your post says page 501 says just what I need. Is that in Dr Z's book because I don't find it.

This also goes with cardiology. On page 501 is says the exact same thing. Diagnostic angiography has to be documented in the report.

Hope this helps some.

erica Ross CIRCC, RCC
 
Erica,

Okay. I gotcha, the CPT guidelines. Funny, I gave him a copy of those two weeks ago and every documentation since has not had "diagnostic" it is even though he has told me they were.

*sigh*
 
Another thing to consider to maybe talk to your provider is, every thing that is coded requires medical necessity if your note that is being coded does not support the medical necessity then ethically it should not be coded and should be questioned. And most certainly will be questioned if it is auditted. Some people may think you dont need a diagnostic explanation for some codes but, if its a scrrening colonscopy then it is simply a screening, but if its diagnostic....why is it diagnostic (previous screening abnormal, cancer, what makes it not a screening)? Medicare has set LCD and NCD guidelines for a reason, and thats medical necessity.
Now allot of Interventional, cardiology require documentation for the necessity of some add on codes and/or to un bundle if they do something that was further and above and beyond the hiarchy, you cant simply put 59 for payment with out the necessity being easily stated in the note.
Just my opinion!
 
You must log in or register to reply here.
Top