Wiki Official guidelines question

[jdazone]

Guideline 1.A.19 -Code assignment and clinical criteria.
"The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider."
Is there a limit to the statement "If there is conflicting medical record documentation, query the provider"?
for example:
if the patient's BMI is 50 and the provider codes overweight with an evaluation of gained 8lbs and needs to lose 10 lbs by the next visit
or the BMI is 30 and the provider codes Morbid obesity with an evaluation that the patient lost 5 lbs in 3 months and will continue on a weight loss journey. Should the coder query for a change of ICD 10 code?
Or can a coder change the code to the correct code?
For example:
provider codes cataract of the right eye, HPI states the left eye, and all documentation points to the left eye. The coder can change the documentation to accurately code for the correct eye.

 

[kayleeevans907]

Both hospitals I've worked for allow coders to change the diagnosis codes based on documentation regardless of what the provider selects in the electronic charge screens. I've had many providers who select the first thing close to what the diagnosis is or they just remember and enter the general/unspecified codes for conditions and never try to use more specific ones (eg. abdominal pain, asthma, etc.) It might be good to check with your practice and see if they have an internal policy but otherwise I'd say change it to match the documentation as long as there's no discrepancies in the note itself.

 

[csperoni]

In my opinion, coders should be allowed to change/correct codes selected by a clinician, based on the written information in the record. That is exactly what they are trained for. However, this could vary based on your employer's internal policies.
If the written information contains conflicting information (such as left vs right), then query is required.
If all written information contains the same information (left eye), but provider selects a code for right eye, most employers will allow a coder to correct the code.