Question for the coders in the group
Are you obligated to code every diagnosis that you see in the chart, even if you know it may not be supported clinically?
One of our docs wrote respiratory failure in her note (one time only), and there was absolutely nothing in the chart to support it. (She is off now and I have no way to query her about it.) I elected not to pick up the code, but my boss told our coder to take the 518.81 because she says the coders are obligated to code whatever diagnoses the physicians have written. Her position is that we should query the physician, and if the doctor won't take off the diagnosis, we code it, and then it becomes the doctor's responsibility to defend the diagnosis if/when we are audited.
Is that your understanding as well?
Renee
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
One of our docs wrote respiratory failure in her note (one time only), and there was absolutely nothing in the chart to support it. (She is off now and I have no way to query her about it.) I elected not to pick up the code, but my boss told our coder to take the 518.81 because she says the coders are obligated to code whatever diagnoses the physicians have written. Her position is that we should query the physician, and if the doctor won't take off the diagnosis, we code it, and then it becomes the doctor's responsibility to defend the diagnosis if/when we are audited.
Is that your understanding as well?
Renee
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
Comments
definition of a reportable condition, per Coding Guidelines? From your
description, it did not meet the criteria for a reportable condition. In
that case, I would consider it an incidental finding. That's also how I
handle atelectasis. Did it meet the definition of a reportable
condition? If so, I query-if not, I don't.
Is there anything else I can do for you?
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Sandy Beatty, RN, BSN, C-CDI
Clinical Documentation Specialist
Columbus Regional Hospital
Columbus, IN
(812) 376-5652
sbeatty@crh.org
"The most important thing in communication is to hear what isn't being
said." Peter F. Drucker
of treatment, I do not code it.
Don
in the chart you are supposed to code. Present - RAC-day coding - you
need to Query for the diagnosis. In the past I have coded some
diagnoses as "secondary" because the physician documentation was not
clinically supported.
There is also the very real example that a condition is mentioned in the
H&P and is resolved w/in 24 hours of admission. If it's supported
clinically you can code.
I recently asked this very same question to a friend/consultant and her
advice was the same - if it's not supported you should Query first and
if it's still in question - not to include.
It's a very fine line you walk between coding something the physician
documents and coding something that is not supported clinically.
N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center