alices
Guru
can someone please help me with this.. I have an ER chart where the Dr has well child exam as the final dx, in the Hpi it says per mom pt has decreased urine output,ed course says benign exam, he did labs and he gave fluids, the remote coder coded oliguria 788.5 as the final dx, I sent it back to her and told her she could not change the dr's dx but she could send back and ask him to clarify dx, well her auditor sent me a note saying that I was wrong and that per outpt guidelines " in the absence of a final dx you can use signs and symptoms" and since it states in the Hpi pt has decreased urine that she had coded correctly.. but the dr has a final dx he put v202 now I know insurance co's don't like that code especially on ER claims but it is a legitimate dx so I don't know why they are saying it can be changed,I sent it back to the dr before receiving this note asking him why he gave fluids if baby had normal exam he stated he gave the fluids because mom complained of decreased urine output, so incase child was dehydrated he gave the fluids but fortunately pt was not dehydrated, so can someone please tell me is she correct? Can we change what he has in that instance? I do not feel comfortable doing this so if it is alright, can you please tell me where I can find it in writing so I can protect my self..thank you and sorry for such a long note, hopefully I explained it right..alice