RE: [EXTERNAL] Question Regarding Criteria and Clinical Judgment
Totally agree with you. That's exactly how the RAC's and auditors justify their denials because a diagnosis may be written but not justified in the documentation.
So here is my question, is it the coder's responsibility to query a diagnosis if the justification is not provided in the medical record. Are they crossing over the line by querying for a diagnosis written only by one doctor and not any other physicians, copied and pasted throughout the progress notes with no further justification or treatment plan, or dropped in the last progress note just before discharge and/or no discharge summary provided by the time the coder needs to drop the account.
Should the coder query for clinical validation or justification before the bill gets dropped based on what they think might be lacking? I think the physician's would get very upset but on the other hand it would eventually train them they need to justify their diagnoses in the record and write down their clinical rationale instead of just writing a diagnosis without supporting it. I guess it all depends on each individual facility and how they want to deal with these issues. If the justification is there, hopefully the denials would decrease somewhat and we would have a better chance in appealing the denial.
So here is my question, is it the coder's responsibility to query a diagnosis if the justification is not provided in the medical record. Are they crossing over the line by querying for a diagnosis written only by one doctor and not any other physicians, copied and pasted throughout the progress notes with no further justification or treatment plan, or dropped in the last progress note just before discharge and/or no discharge summary provided by the time the coder needs to drop the account.
Should the coder query for clinical validation or justification before the bill gets dropped based on what they think might be lacking? I think the physician's would get very upset but on the other hand it would eventually train them they need to justify their diagnoses in the record and write down their clinical rationale instead of just writing a diagnosis without supporting it. I guess it all depends on each individual facility and how they want to deal with these issues. If the justification is there, hopefully the denials would decrease somewhat and we would have a better chance in appealing the denial.