Wiki Physician office coding

[kst73pkvw]

A discussion came up recently that has me wanting to get ideas and documentation reference from other coders out there. In a Physician office setting the physician will document his/her diagnosis in the assessment and plan portion of the note. If the coder has any question regarding the documentation we query the provider. Another individual stated that if the physician listed a symptom or diagnosis in the body of the note, unrelated to the documented diagnosis listed in the assessment and plan, they could abstract code that information. An example would be: the physician diagnosed the patient as having dysuria only, but in the body of the note he mentioned lumps on the legs. I am curious to know others thoughts on this topic.

 

[michelleholt]

I know that when I read a physician's documentation I code what is in the assessment only. If the body of the note or the exam portion has something that wasn't in the assessment, I'll ask the physician to take a second look at the note to make sure the finding, such as the lumps, wasn't missed by accident in the assessment. If not, I only code what the physician has in the assessment. Hope this helps.

 

[lstaniscia]

Doctors will often document all of pt's ailments in the review of systems. The only billable DX however is the one that meets medical necessity for the visit.
If patient is being seen for treatment of venous ulcer, it does not matter that he/she also suffers from dry eye. It has no bearing on the chief complain.

 

[smidge1]

If the physician notes something else in HPI and exam of possible relevance and is not noted in chief complaint, the coders are responsible to query the physicians to ask for the Dx. and documentation to support what they have noted. They are the ones seeing the patient and know what is going on. I always query the doctors and 99% of the time get the additional information needed to support what was noted. The other times they will let me know that they are merely noting it for future reference. Rule of thumb always ask, the additional documentation has always met requirements to meet medical necessity thus billable.