Wiki Does it matter that the condition is not marked?

[torresreb]

our visit forms have very specific conditions providers will mark should the patient have it ... example;

* diabetes *Type I *Type II

*w/Retiinopathy *w/PVD *w/Peripheral Neuropathy

*w/Chronic Kidney Disease

the asteriks are boxes that the provider will √ off should the patient have the condition and/or manifestation .... my question ... if the TypeII and w/CKD boxes are checked and the assessment and plan completed but the diabetes box was not checked am I still able to code 250.40 585.9?

Or will the form have to be sent back to the provider to check the diabetes box?
your opinion is appreciated.

 

[Pam Warren]

Please don't code off a billing form. You must code off the physician's documentation. The billing form is not part of the legal medical record. It doesn't matter what he checked off...what matters is what he documented as a diagnosis on the progress note. Can you view the note/EHR prior to dropping the claim? Can you guarantee that his documentation always supports entirely what his billing form indicated?

I know that's not an answer to your question, but it's the answer to compliant coding.

 

[torresreb]

when you say billing form do you mean what is actually sent to the insurance when payment is requested? If so, then this isn't a billing form.

I believe the check off boxes were put in place to make it easier for the provider to document the assessment and treatment plan ... so there are three columns one is the information I mentioned then the assessment and the last column is the treatment plan ....

Assessment:
= condition stable

Treatment Plan
=patient to f/u w/pcp regarding labs and medication adjustment if necessary
=patient to continue to take januvia,metformin and glipizide as prescribed
=encouraged less carbs and increase in veggies
=improve on diet and exercise

no where does it have the 'word' diabetes . which is what I'm concerned about .. I welcome any type of opinion more so when it comes to compliance ... thank you for your time!!

 

[Pam Warren]

If they're using this form as part of the medical record, than the language on the form has to support the diagnosis that you report. So without "diabetes" as part of their assessment list (checkoff), you can't really support a diagnosis of diabetes. They either need to state it, or have the ability to indicate it so that the verbiage (not the code) is on the medical record.