kanoepascual
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We're at a crossroads on this scenario & would really appreciate feedback & if possible valid resources:
Per Coding Clinic, Fourth Quarter 2018, and also noted in the Official Guidelines for Coding and Reporting, Section I.A.19, “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. At what point, if ever, does documented clinical criteria (e.g., a BMI of 18 with a diagnosis of morbid obesity) constitute conflicting documentation that would potentially be an issue of undue overpayment? Does the responsibility always rest with the provider’s discretion, or are there scenarios where coders may not pick up the diagnosis based on clinical indicators? In retrospective coding scenarios where querying the provider is not feasible and a final coding decision is required, should coders adhere strictly to the provider’s documented diagnosis per Coding Clinic guidance, or disregard the diagnosis all together to address potential conflicts? (Granted if there is NO BMI noted, there is nothing conflicting per se so this inquiry is only asking when it seems to be conflicting).
Also, please clarify if this portion of the General portion of the ICD10- CM Guidelines I.B.14 where it states: If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s provider should be queried for clarification has a role in determining if coders should query and if unable to query, should coders disregard the dx as conflicting? Thank you!
Per Coding Clinic, Fourth Quarter 2018, and also noted in the Official Guidelines for Coding and Reporting, Section I.A.19, “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. At what point, if ever, does documented clinical criteria (e.g., a BMI of 18 with a diagnosis of morbid obesity) constitute conflicting documentation that would potentially be an issue of undue overpayment? Does the responsibility always rest with the provider’s discretion, or are there scenarios where coders may not pick up the diagnosis based on clinical indicators? In retrospective coding scenarios where querying the provider is not feasible and a final coding decision is required, should coders adhere strictly to the provider’s documented diagnosis per Coding Clinic guidance, or disregard the diagnosis all together to address potential conflicts? (Granted if there is NO BMI noted, there is nothing conflicting per se so this inquiry is only asking when it seems to be conflicting).
Also, please clarify if this portion of the General portion of the ICD10- CM Guidelines I.B.14 where it states: If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s provider should be queried for clarification has a role in determining if coders should query and if unable to query, should coders disregard the dx as conflicting? Thank you!
