Codeable Diagnosis or Query Needed?
Please share your opinion with explanation:
The attending neurologist orders an EEG and documents encephalopathy in his interpretation.
Is this a codeable diagnosis?
Coding felt a query for clarifying the clinical signficance of the aforementioned encephalopathy is necessary referencing the following guidelines.
Official Coding Guidelines for Coding and Reporting, Section III B
B. Abnormal findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.
Please note: This differs from the coding practices in the outpatient setting.
However, I think an EEG interpreted by the attending neurologist is different than X-rays, labs or pathological reports etc. that are interpreted by physicians not actually seeing the patient.
the term "Other diagnostic results" included the guidance above technically applies to EGDs and Colonoscopies interpreting by the attending gastroenterologists or Cath Lab reports by the attending cardiologists, etc.
What do you think?
Thank you for your input,
Thank you and Happy New Year!
Charlie Morell
Lead CDI Specialist
Regional Medical Center Bayonet Point
Hudson, FL
The attending neurologist orders an EEG and documents encephalopathy in his interpretation.
Is this a codeable diagnosis?
Coding felt a query for clarifying the clinical signficance of the aforementioned encephalopathy is necessary referencing the following guidelines.
Official Coding Guidelines for Coding and Reporting, Section III B
B. Abnormal findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.
Please note: This differs from the coding practices in the outpatient setting.
However, I think an EEG interpreted by the attending neurologist is different than X-rays, labs or pathological reports etc. that are interpreted by physicians not actually seeing the patient.
the term "Other diagnostic results" included the guidance above technically applies to EGDs and Colonoscopies interpreting by the attending gastroenterologists or Cath Lab reports by the attending cardiologists, etc.
What do you think?
Thank you for your input,
Thank you and Happy New Year!
Charlie Morell
Lead CDI Specialist
Regional Medical Center Bayonet Point
Hudson, FL
Comments
I agree that according to coding guidelines (below B- Abnormal findings), you can not code from an interpretation on an EEG. The attending physician or any consultant on the case should document this condition in
Is this an inpatient record? If so, I would think the doc would give more of inclination as to why he ordered the EEG or if the doc is the attending physician of record there has to be a reason for the patient to be admitted by a neurologist. If he really just does not give you anything, then yes you would need to query. On the other hand, if this is an outpatient record you can code from the report - I'm just not sure if encephalopathy would pass through the edits in your state.
Thanks, Carmella
Carmella Gay, CPC-H, CPAR
AHIMA-Approved ICD-10-CM/PCS Trainer
Documentation Specialist
Case Management
Tift Regional Medical Center
(229) 353- 6169 - Office
(229) 353-6265 - Fax
Someone gave me a great way to distinguish that I thought I would pass along:
You can code from procedures but you cannot code from studies i.e. EEG, echos etc. without the information being documented elsewhere in progress notes or consults.
Happy New Year all!
Charlie