Example:
Plan says: suspect patient may have stress fracture. Will send for bone scan. Assessment says: Stress fracture left foot.
Bone scans are usually not scheduled for at least a few days to a week later.
Plan says: pain may be due to tendonitis. Assessment says: peroneal tendonitis.
And would you code the plantar fasciitis on this one?: Clinically she appears to continue to have issues with Tarsal tunnel and possible plantar fasciitis. She has tried numerous treatments without relief. Dicussed again other options may include trial of tarsal tunnel release and plantar fasciotomy.* Patient elected to proceed with this.
And, yes, the provider has been told, in a coding meeting, that we can not code unconfirmed diagnoses and examples were given.
Plan says: suspect patient may have stress fracture. Will send for bone scan. Assessment says: Stress fracture left foot.
Personally I'd code this S99.922A Unspecified injury of left foot, initial encounter. In order to diagnose a stress fx, the bone scan would have to be completed to confirm.
Plan says: pain may be due to tendonitis. Assessment says: peroneal tendonitis.
Peroneal tendinitis
could be diagnosed based on the history and exam. If the documentation includes the symptoms normally associated with peroneal tendinitis, which includes pain, then I'd probably code it as peroneal tendinitis.
Clinically she appears to continue to have issues with Tarsal tunnel and possible plantar fasciitis. She has tried numerous treatments without relief. Discussed again other options may include trial of tarsal tunnel release and plantar fasciotomy.* Patient elected to proceed with this.
Ugh. Again, plantar fasciitis can be diagnosed based on history and exam. But the problem I personally have with this is that both tarsal tunnel syndrome and plantar fasciitis can have the same symptoms. As a matter of fact, when a patient presents with heal pain, if a provider is considering a diagnosis of TTS, plantar fasciitis is one of the conditions included in a DDX. Additionally, if the patient is diagnosed with TTS (G57.5-), that code block has an Excludes1 for "current traumatic nerve disorder".
I think in this case, I'd code for the TTS only. You
might have been able to code for the plantar fasciitis since it can be diagnosed during the visit, except in this situation, the patient is stated to have TTS. There's really no way of knowing if the symptoms in the documentation would go one way or the other unless the provider specifically spells it out. And, if it turns out the patient has a nerve condition, not plantar fasciitis, then the coding guidelines get thrown into play.
If the provider has already been instructed to make his/her documentation more clear and specific and that's not happening, I would bring it up with my supervisor. The amount of work you have to put in just to bill one visit is unacceptable. I'm not sure how large the office/facility is where you work, but I would assume someone there cares about the bottom line. If that's not your supervisor's role, and if you are able to approach the person who is concerned about profits, it might be best to explain that this problem is slowing down the amount of claims billed per day, which is subsequently slowing down how quickly reimbursement is received, not to mention the amount of time you have to spend on coding each encounter (meaning lower productivity). From a managerial/administrative perspective, I'd be furious if this was going on in the facility I work at.
Not to be passive-aggressive here, but you
could query the provider on each one of these that you get because it IS his/her job to know what conditions cause what and what symptoms means what and what can be diagnosed during an exam and what can't, etc. That's not your job. That might make a point... okay it's totally passive-aggressive
