Wiki ProFee vs Hospital diagnostic coding

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jeanettejg

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I need some help! I need to find a reference, one way or the other, that supports/does not support the ability of a professional coder to use the entire chart when coding TODAYs visit.

I've been trying to explain why this is not how things work. If an auditor pulls the chart for review for the visit on 3/3/17, what is released is the documentation from 3/3/17. So if a diagnosis is coded on that visit that is not documented on that visit.... guess what..

I am a former Compliance Auditor under a CIA (Corporate Integrity Agreement) who now is on the facility side. When talking to my professional fee counter parts, they are told they can use the whole chart to code from.. (?) On the facility side we are confined to the account/stay that we are currently coding.

If anyone can provide reference either way as to the professional fee side, I'd appreciate the help. I've been looking under all the CMS literature but have been unsuccessful. Thanks in advance!
 
a physician code codes by encounter not the whole chart. If it is not documented on that encounter then the pro-fee coder cannot code it. The inpatient facility coder also codes by encounter, however the facility encounter is the entire stay and they code after discharge not each day.
 
You would think.. but I need a reference. Anywhere you know of I can look? Thank you for the reply!
 
Following this discussion - - We are having the same discussion here. Our director wants us to provide guidance from a source like CMS or the ICD-10 guidelines.

Any source that anyone can provide would be greatly appreciated!

Karen
 
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