Coding pre op imaging
How do other facilities code imaging that was obtained prior to an inpatient encounter for surgical cases? For example, if pre-operative imaging from two months before surgery showed a new broad-based herniation at L5–S1 with compression of the traversing left S1 nerve root, but the provider did not document myelopathy during the admission, can this MRI be used as supporting evidence for a query?
Comments
Good afternoon,
Yes, it can be used per the guidance from the query practice brief as long as you have relevancy in the current encounter. Prior encounter information can be utilized in order to query a current encounter as long as it is relevant to the current encounter. You must have a "trigger" in the current encounter to use prior information.
Queries must be accompanied by clinical indicator(s)/evidence that:
a. Are specific to the patient and episode of care
b. Support a more complete or accurate diagnosis or procedure
c. Require clinical validation of a reported diagnosis not supported
by the health record, please reference the latest update to the practice
brief, Clinical Validation: The Next Level of CDI, to learn more about
clinical validation.
d. May be acquired from the current or previous health record, if
clinically pertinent to the present encounter (Please reference Previous
Encounter section for more information)
Hope that helps, Deanne Wilk