Wiki To code or not to code

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ChelleLeavitt

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My providers are very good at dictating elevated lab results, i.e. pt's IgG level is low, which is technically "HYPOGAMMAGLOBULINEMIA". My instinct is to not code it because the Dr. didn't dictate it as hypogammaglobulinemia. But I would like other opinion's on this.

Thanks :confused:
 
I am in agreement with you, do not code. Providers must document the diagnosis, coders can not "assume" anything. If it hasn't been longer than the allowable time to amend the note, you could query him and possibly have him amend his note with the diagnosis.

Cherene
 
A code is not allowed to code from lab results. They must have physician interpretation in the chart note. A coder may code only provider render diagnosis and is not allow to decide what a given lab result represents.
 
Thanks

Thank you for your input. I will stick to NOT coding them out. Funny thing happened not too long ago. Dr. dictated that the pt's IgM was low, but I only coded it to abnormal lab results. Later he wanted to treat the pt for "Hypogammaglobulinemia", but had to explain to him that I needed him to dictate the Dx out, and not just a low result. It scares me how Dr's think sometimes. Yes I know what a low IgM is, but if you don't state it, I can't code it.

Thanks for the input. :)
 
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