Wiki HELP!! Diagnosis coding question

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dokeef01

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I have a provider who uses many diagnosis codes and I do not believe they are supported.

Example: 5y/o with cc: runny nose, cough, congestion x 1day. No fever. Complete head to toe assessment is checked as normal exept nose-mucus. Diagnoses are; URI and in-toeing. He prescribed Rondec DM and gave an orthopedic referral.

Please give feedback on whether this provider can use a diagnosis of in-toeing.

Thanks!!!
 
I would not look at this negatively as in a higher e&m but as good for the child to find if this toeing-in is a problem at this age. I would use it for a Dx along with the respiratory problem. Just my opinion though.
 
My problem with this MD is that the children come in for a complaint. The exam is usually checked as normal but then there are a bunch of diagnosis codes listed. I was under the impression that a diagnosis code had to be supported by the documentation- HPI, ROS, and exam. In this example, there is no mention of any in-toeing complaints by the family and the exam for extremities is marked as normal. This particular provider's documentation always has a chief complaint, however, he never documents any HPI or ROS. Even the exam is usually normal. For instance, a patient c/o sore throat x 1 day and his exam states normal. (He always marks a complete exam no matter what they come in for) Then he does throat cultures, cbc, flu assays, etc. The diagnosis is tonsilitis. As a Registered nurse, I don't see how you can have a diagnosis of tonsilitis (inflamation of the tonsils) when the throat exam is documented as completely normal.
 
diagnosis coding

Welcome to the doctor version of coding. If it was a problem, he would probably have been audited by now.

I agree with the last reply you got.
 
He can't code the DX for in-toeing as it is unsupported by the note. If he did a head-to-toe then it should show as an abnormality in the MS system.

Any DX assigned must be supported by the note either in the HPI as a presenting problem or as found on exam. Makes me wonder if he is just "clicking buttons" on his exam template
 
(These are my opinions and should not be construed as being the final authority. Other opinions may vary.)

[stepping up on the soapbox]

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_024277.hcsp?dDocName=bok1_024277

Go to the above link and give it a good read, then determine what your exit strategy from this job is. You, as the coder, are legally liable for the veracity of the codes that are submitted. If you know the codes are bogus, then you will stain our profession by continuing to work for this physician - AND you could go to prison as complicit - AND you must not remain silent about the unethical behavior of this physician - blow the whistle!!!

[stepping down from the soapbox]

Richard Mann, your pain management coder
rkmcoder@yahoo.com
 
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