Official source for answer to this question: Can you assign a code from physician orders?

cmorell

I have always been told that a diagnosis cannot be coded from physician orders. In fact it is documented in a presentation in the ACDIS Conference files 2009 power point presentation by Lynn Sprysak on how to do a methodical chart review.

Now, I am being told a diagnosis CAN be coded from physician orders. But, I am looking for an official reference, Coding Clinic, CMS, etc.
Does anyone have one?

Thanks!

ssalinas

From Coding Clinic 2005 3rd Qtr - this applies to long-term or short-term I believe -

Coding from physician orders
      Coding Clinic, Third Quarter 2005 Page: 19 to 20 Effective with discharges: September 15, 2005
      Related Information


Question:

A new resident of a long-term care facility is prescribed ativan. In the order the physician documents, "DX: Anxiety." Would it be appropriate to code anxiety based upon the documentation of this diagnosis in the physician order?

Answer:

It would be appropriate to assign a code for anxiety based upon the physician documentation of the condition in the physician?s order. This advice applies to both verbal and written orders from physicians. As long as the physician documents a diagnosis and there is no conflicting information elsewhere in the medical record, it is appropriate to code the diagnosis. If there is evidence of a diagnosis within the medical record and the coder is uncertain whether it is a valid diagnosis, it is the coder?s responsibility to query the physician to determine if this diagnosis should be included in the final diagnosis.




© Copyright 1984-2013, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

Sharon Salinas, CCS
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
ssalinas@barlow2000.org

paxneros

So if a physician wrote, "IV Vancomycin for MRSA Pneumonia" in his Orders you wouldn't code it?

Or if the physician documents, "Admit for MRSA Pneumonia" as his first order?

I was taught that diagnoses may be taken from most anywhere in the chart but Radiology - except in specifying where - say a more specific area of a fx - or in Pathology - on the Inpatient side.

Our physician consultant also teaches other physicians to document as above in their Orders.

Norma T. Brunson, RHIA,CDIP,CCS,CCDS

sharon.cole

The coders that I work with will not. They say that is not a diagnosis list and therefore will not count dx written to substantiate an order for a medication or a test. I agree with them not using the “admit to ICU for ___” - there’s been no study yet to determine for the diagnosis for sure. But if the physician is ordering a medication to treat a specific condition, seems like it should be ok. I agree with them regarding not counting a dx listed for a test as again, that has not yet been confirmed. “It’s all just so very gray” – a direct quote from my coders for most questions that I ask them☺
BUT, just like I would question or refuse a nursing task that made me uncomfortable, I have to allow them the same right with their coding.

Sharon Cole, RN, CCDS
CDI Specialist
254.751.4256
Sharon.cole@phn-waco.org

cmorell

Thank you so much Sharon! That is exactly what I needed.
That is why I appreciate CDI talk so much. I prefer to have references to cite when I explain coding rules.

evanspx@sutterhealth.org

I am aware of the statement in Coding Clinic, but I do not code MRSA Pneumonia under these circumstances. The staff will order many treatments as conditions are being considered, and suspected conditions are routinely noted in the orders and notes, but later are ruled out.

One example would be treating a patient for suspected MI, but the MI is later ruled out based on further diagnostic efforts.

I look for ‘more’ than the orders alone in order to justify code assignments, and we should consider the updated Query Practice Brief stating there are time a CDI/Coder is compelled to ‘verify’ certain diagnostic statements.

In my view, many of the conditions listed in the orders (and notes) are ‘only’ working diagnoses, and are later deemed not present.



Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

ssalinas

The question was if it is ok to code diagnoses found in the physician’s orders and the answer to that is yes. That said, we all use our professional judgment in applying any code.

I will code a pressure ulcer to a specific location even if the physician only documents the location when ordering treatment if there is documentation of the ulcer stage and treatment rendered in the wound care notes. Often times that is the only place the physician notes the location.

If a diagnosis found anywhere in a record is later ruled out, then of course it would not be coded. This is true whether it was found in the orders, ER, H&P or anywhere else.

Sharon Salinas, CCS
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
ssalinas@barlow2000.org

evanspx@sutterhealth.org

The answer is not, ‘yes’, but ‘it depends’.

I feel it a bit of a simplification to cite a Coding Clinic that is very, very old, and advise that one may code directly from orders. In light of recent developments in our new Query Practice, this is not the case. I actually know of some in the industry that literally follow this particular advice in Coding Clinic, and code directly (solely) from the orders. This is not Best Practice.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

sharon.cooper@owensborohealth.org

I would also code from Physician Orders, if diagnosis is documented. We are encouraged to code from the entire record.


Sharon Cooper, RN-BC, CCS, CCDS, CDIP
AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
Manager Clinical Documentation/Appeals/MDS/PPS

Owensboro Health Regional Hospital
P.O. Box 20007
Owensboro, KY 42304-0007

sharon.cooper@owensborohealth.org
(270) 417-4612 Office
(270) 316-9088 Cell
(270) 417-4609 Fax

elizabeth.hynd

We had an FTI Boot camp and were told that we could code from the orders when the diagnosis is clinically supported by the medical record. According to Faye Browne chapter 4, the Medical Record as a Source Document pg 39 "The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated."
Usually there is time for investigation and opportunity to query, however occasionally as in the case of a mortality chart early in the stay everything comes to a halt and documentation may be limited.
Interesting question.


Elizabeth Hynd RN, BSN, CPUR, CCDS
Clinical Documentation Specialist
863-687-1100 ext. 7313