3M's opinion re DVT Documentation
I posed the question regarding DVTs and site specificity from ultrasounds to 3M Nosology. The response is below. I will stick with my original opinion that ultrasounds can be used to identify the specific site of the DVT. You cannot take a dx from a radiology report but you assign site specific codes to dx that is already documented by the physician I the medical record.
Resolution
Hello, Sharon,
According to the AHA Coding Clinics, First Quarter 2004, pages 20-21 and First Quarter 1999, page 5, it is permissible to use radiology reports to assign site-specific codes for documented diagnoses. The same logic can be extended to the use of ultrasound and doppler reports to further define thrombus/embolus location for documented deep venous thromboses.
Thank you,
Leslie Hudson, RHIA, CCS | Nosology Coding Support
3M Health Information Systems
575 West Murray Blvd, Murray | UT 84123
Office: 801 265 4316 | Fax: 651 732 8699
lghudson@mmm.com | support.3mhis.com
Sharon
Resolution
Hello, Sharon,
According to the AHA Coding Clinics, First Quarter 2004, pages 20-21 and First Quarter 1999, page 5, it is permissible to use radiology reports to assign site-specific codes for documented diagnoses. The same logic can be extended to the use of ultrasound and doppler reports to further define thrombus/embolus location for documented deep venous thromboses.
Thank you,
Leslie Hudson, RHIA, CCS | Nosology Coding Support
3M Health Information Systems
575 West Murray Blvd, Murray | UT 84123
Office: 801 265 4316 | Fax: 651 732 8699
lghudson@mmm.com | support.3mhis.com
Sharon
Comments
AHA Coding Clinicâ for ICD-9-CM, 1Q 1999, Volume 16, Number 1, Page 5
Question:
A patient comes into the hospital with a fracture of the femur. Upon discharge, the physician lists in his final diagnostic statement, fracture of femur. However, when reviewing the medical record, the x-ray report states that the site of fracture is the shaft of the femur. Is it appropriate to use the x-ray results to provide further specificity to this diagnosis for coding purposes?
Answer:
Assign code 821.01, Fracture of other and unspecified parts of femur, Shaft. Coders should always review the entire medical record to ensure complete and accurate coding. If the physician does not list the specific site of the fracture, but there is an x-ray report in the medical record that does, it is appropriate for the coder to assign the more specific code without obtaining concurrence from the physician. However, if there is any question as to the appropriate diagnosis, the coder should consult with the physician before assigning a diagnosis code.
Paul
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739