Coding before query answered
Hi, all,
I have a question that I hope all the coders in the group will answer. The coders @ my facility will code a dx, often the PDX, even when they have placed a query to the MD for clarification of the SAME Dx. This is confusing, because when I review the abstract, I think it is coded as "final" but then I find there is a retro query. Example: Sepsis coded as the PDX, but there is retro Query for "sepsis ruled in, ruled out, other..." It was my understanding that Prof. Coders could only code to the level of information in the chart at the time they see it, and must wait for MD response to add diagnosis. Is this correct? Is there some reference in the coding guidelines, or other resource that speaks specifically to this?
Do other facilities do this same practice?
thanks very much,
Becky Mann
I have a question that I hope all the coders in the group will answer. The coders @ my facility will code a dx, often the PDX, even when they have placed a query to the MD for clarification of the SAME Dx. This is confusing, because when I review the abstract, I think it is coded as "final" but then I find there is a retro query. Example: Sepsis coded as the PDX, but there is retro Query for "sepsis ruled in, ruled out, other..." It was my understanding that Prof. Coders could only code to the level of information in the chart at the time they see it, and must wait for MD response to add diagnosis. Is this correct? Is there some reference in the coding guidelines, or other resource that speaks specifically to this?
Do other facilities do this same practice?
thanks very much,
Becky Mann
Comments
Are these being dropped or finaled with the query still out? If that is the case, the coder must be pretty confident of the response they are going to get based on the documentation that is available and/or on their knowledge of the physician. This is not a good practice but I know facilities that instruct their coders to do this. If the response does not support the assigned dx, they can re-bill.
If the acct/abstract has not been dropped or the abstract finaled, then this is a common practice. The coder will code to what they expect the response to be. When the query is completed, the final coding will be done based on what the response is.
As long as the bill is not dropped/abstract finaled, it is totally up to the facility how it is handled. As far as dropping accts with an outstanding query, that is more dicey and could become an issue if the eventual does not support the coding/DRG submitted for payment. Rebilling a lot of accts is generally not considered a smart thing since it can cause red flags to payers.
Mostly they will code the chart to the point where they need the documentation.
Our Lead Coder keeps a report of outstanding queries post discharge, As soon as the coder submits the query it is added to this report and it is sent out to the CDI personnel.
Nbrunson, RHIA, CCDS
Our coders will do the same thing - they just don't finalize the case. If the MD doesn't document as they expect they update the codes prior to finalizing the case. It makes me crazy!!
I have worked at several hospitals and that is the way it has been done in all of them.