Wiki Hospital physician services dx coding

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ajackson7506

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Question.....When billing for our physician hospital services, eg, initial visits, daily calls, discharges, etc, is it appropriate to use the physician's documentation for diagnosis coding, eg, daily progress notes, H&Ps, discharge summaries, etc?

Our local hospital's HIM department insists that clinic physicians should use the same diagnosis as those listed on the hospital's attestation/abstract sheets (which may include "rule out" "question" type diagnosis).

Thanks for your assistance!

A Jackson, CPC
 
You need to use the documentation that your physician dictates - his H&P, consult, progress notes, discharge. The HIM Dept. doesn't know what they are talking about. ;)
 
Remind your HIM department that physicians are always bound by the OP Coding Guidelines listed in ICD-9. They should also be using only the "definitive" diagnoses on OP clinics, etc. IP is the only place where the standards are different for physician and facility.
 
If coding for Risk Adjustment within a health plan, is it safe to take all information from a discharge summary. Not just the discharge dx listed, but can you for example code a
V46.11 respirator dependency status that is described within the note which was done 2 days prior to discharge?
 
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