1formissy
Guru
Hello Fellow Auditors,
By day, I am a coder, by night, an Auditor. So, I am always going back and forth with this issue and thought I would reach out to my colleagues for their insight.
Our physicians do diagnostic imaging interpretations for the hospital. When coding those services, many times I come across documentation where there is no sign/symptom/definitive diagnosis. The indication will say, "Trauma."
So, our coders are forced to look in the EMR to find a definitive diagnosis/sign/symptom.
As an Auditor, this does not sit well with me, because the documentation MUST support the service(s) reported. Therefore, if a claim comes across as S09.8XXA (Head injury), but the documentation says Trauma and nothing else, (conclusion in the record will say something to the effect of "No abnormal findings), I do not find that compliant.
I searched online for some indication from Medicare regarding this, and found nothing.
Comments?
By day, I am a coder, by night, an Auditor. So, I am always going back and forth with this issue and thought I would reach out to my colleagues for their insight.
Our physicians do diagnostic imaging interpretations for the hospital. When coding those services, many times I come across documentation where there is no sign/symptom/definitive diagnosis. The indication will say, "Trauma."
So, our coders are forced to look in the EMR to find a definitive diagnosis/sign/symptom.
As an Auditor, this does not sit well with me, because the documentation MUST support the service(s) reported. Therefore, if a claim comes across as S09.8XXA (Head injury), but the documentation says Trauma and nothing else, (conclusion in the record will say something to the effect of "No abnormal findings), I do not find that compliant.
I searched online for some indication from Medicare regarding this, and found nothing.
Comments?