dirtymartini77
Guest
Hello. Relatively new to the coding world and experiencing some confusion on our team regarding the use of unspecified codes that have previously been used in the patient's past medical record/history as a specified version. (Example: Unspecified A-Fib for this encounter, but the pt has numerous, previous encounters: office visits, procedures, etc. with a Chronic A-Fib code)
Are we allowed to change the existing unspecified code to the specified version if there is medical record documentation?
I am also stating for the purpose of this particular example, I do also understand that the documentation must reflect that (chronic) condition. In my specialty, (cardiology) the providers tend to drop the encounter with the unspecified codes as a default, just to get them into the queue and from there we are to specify. I am trying to clarify that I CAN or CANNOT use a pt's past medical record to extract a specified code and change it.
Thanks so much in advance!!!!
Are we allowed to change the existing unspecified code to the specified version if there is medical record documentation?
I am also stating for the purpose of this particular example, I do also understand that the documentation must reflect that (chronic) condition. In my specialty, (cardiology) the providers tend to drop the encounter with the unspecified codes as a default, just to get them into the queue and from there we are to specify. I am trying to clarify that I CAN or CANNOT use a pt's past medical record to extract a specified code and change it.
Thanks so much in advance!!!!