RE: Coding of Isolation - orders
Some facilities may have their own coding policies which may prohibit coding from orders. However per CMS and Coding Clinic all sources of provider documentation may be used for coding purposes.
· 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. (CC 2005 3rd Qtr Page 19-20)
· As someone said earlier, coders can pick up diagnoses from H&Ps, the body of the medical record, orders, anesthesia assessments performed by physicians or those approved by facility to establish dx, operative reports, discharge summaries, etc.
Thanks,
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
· 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. (CC 2005 3rd Qtr Page 19-20)
· As someone said earlier, coders can pick up diagnoses from H&Ps, the body of the medical record, orders, anesthesia assessments performed by physicians or those approved by facility to establish dx, operative reports, discharge summaries, etc.
Thanks,
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org