Wiki Help dx coding/cci question

[elisaarb]

For a normal delivery an epidural for labor is performed by the anesthesiologist. We receive the bill sheet from the MD and the Dx indicated by the doctor is 650. Normally we are not given the doctors pre-op intake with the billing sheet.

We recently had an audit and the auditing company requested the intake sheet from medical records...it was indicated on the intake that the patient was a smoker and had small amt of amniotic fluid.

The Auditing company in turn told us that for this particular case we should have coded dx as 658.01 and 649.01.

My question is this.....since we do not normally get the pre-op intake and have no knowledge of the pt's history etc and the MD gives us the Dx as 650 on bill sheet.....is it really wrong to use 650? Does it impact the CCI rules if we do? It certainly doesnt impact the payment.

Further is it a normal practice to get the pre-op intake from the anesthesiologist? We ususally just get the bill sheet and anesthesia record and have access to the Operative Reports online with the facility.

Need your help, your advice on this one as soon as possible so we can move forward in the right direction!!

THANKS

 

[hgolfos]

One of the biggest issues I've run into over the last 9 years as an anesthesia and pain management coder is that we frequently don't have access to all the pt's information. Due to the nature of the specialty we're lucky to get a charge sheet, demographic info and an anesthesia graphic record. I think that if your doctor indicates 650 it is perfectly acceptable to bill it. You can't go chasing down the entire medical record of every patient, it just isn't financially feasible. Having said that, I would caution you, that you are charged with coding to the highest specificity possible. So, in light of that, if you are able to easily get the pre-anesthesia intake info on all your patients I would recommend it, as they often have very useful info included in them.