Wiki Podiatry Coding Ohio and Michigan questions

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mdamschroder

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We have an auditing company auditing our notes and coding for nail trims and diabetic exams. They are telling us that we CAN NOT code from the body of the note, only from the Assessment and Plan. For example, the med list is in the body of the note showing the patient is on insulin but in the assessment and plan the Dr does not have "with insulin" then we have to message the Dr to have them add it. Anybody have any experience with this. We are drowning!!!
 
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That's counterproductive! I disagree with this advice. However, with that said, if it is the diagnosis coding you are referring to it's best to code what is assessed, what is the doctor providing?
 
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podcoder70 said:
That's counterproductive! I disagree with this advice. However, with that said, if it is the diagnosis coding you are referring to it's best to code what is assessed, what is the doctor providing?
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I code what is assessed. We are having so many problems with this auditing company. It is getting very frustrating.
 
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mdamschroder said:
I code what is assessed. We are having so many problems with this auditing company. It is getting very frustrating.
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You are not required to abide by their advice. If they cannot provide supporting data/documentation to their "rules" then work directly with your doctor to determine if a document needs to be amended. If the doctor documented the treatment of long thick nails on a dm patient and gave B35.1 and DM Neuropathy E11.42, use those codes. I am not clear as to why they are stating the icd10 has to say "insulin". What am I missing?
 
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