Assuming DX

[Radcoder86]

If a provider diagnosed a patient with acute sinusitis and leaves it unspecified, but in the note states maxillary tenderness, I am not allowed to assume that the diagnosis is really acute maxillary sinusitis, correct? I have a lot of pressure on me to code off of symptoms the doctors put in their notes since they won't specify when they list their diagnoses. I've always been taught I'm not allowed to do this.

 

[mitchellde]

While you should code from the narrative note always, the note must be clear. You cannot interpret maxillary tenderness as anything. You will need the provider to document that sinusitis in of he maxillary sinus.

 

[Radcoder86]

Thank you!

 

[Radcoder86]

I just had another note come across my way that had to do with sinusitis. The doctor didn't state whether chronic or acute, but in the note stated the patient was having symptoms for a week. I asked him to specify in his assessment whether acute or chronic and he told me he shouldn't need to put that down and I should be able to extract the information from the note and know that it's acute and code it as such. Do you agree I should have just coded it as acute even though he didn't specify?

 

[valleycoder]

You would code acute but in a perfect world, it sure would be nice if he'd specify.

 

[chef]

I would code Acute, but your physician should be documenting this for you to accurately code. Its his job to do document specifically. Otherwise your only option is to ask him. also if no area of sinus is documented you can use unspecified. But it should be dictated that way.

 

[thomas7331]

The ICD-10 guidelines are that sinusitis not stated as acute or chronic would be coded as chronic. I wouldn't recommend coding acute just based on the statement that the patient had had symptoms for a week, it's technically not correct.

 

[Radcoder86]

Thank you all for your replies and opinions.