Wiki Audit

[Mindy Davis]

We just went threw a coding audit and I got dinged pretty good for my coding levels being to low and not placing the DX codes in the correct order. Can anyone recommend a list of medication that are consider high risk I think that is where I am dropping the ball. And as far DX codes go I have coded off the CC 1st and then findings second and per the audit that's wrong to. I guess I need allot of help. Will appreciate and I can get very frustrated right now.

 

[eadun2000]

We just went threw a coding audit and I got dinged pretty good for my coding levels being to low and not placing the DX codes in the correct order. Can anyone recommend a list of medication that are consider high risk I think that is where I am dropping the ball. And as far DX codes go I have coded off the CC 1st and then findings second and per the audit that's wrong to. I guess I need allot of help. Will appreciate and I can get very frustrated right now.

You do not code the cc first if the first dx is not the same as the cc. For instance, patient presents for ear pain. Dx is otitis media. You would not code 388.70 as primary and 382.9 as secondary. That is just plain coding. You may want to research some sites that can provide you fundamental coding. Other than that, google things that you do not know. Sometimes you can find a site that gives awesome info that is easy to understand. Just look around and see what you can find. Also, ABOVE ALL.... ask your auditor why the specific mistake was counted and what do you need to do to fix it. It is always a part of the auditors job, not only to audit, but to give education and instruction. If education and instruction are not given, what is the point of the audit? Audits should always be viewed as positive so you can not only find out what you are doing wrong, but how to fix it so you do not do it again in the future. Hope this helps some.

 

[Mindy Davis]

Thanks got a couple more ?'s

Thank you. We use T-Charts at our facility and our Providers do not list in order the Dx codes I need to use 1st. They just write several in the Clinical Impression Box. So I always coded CC 1st and then findings. How do you know which DX code needs to be place above another DX code. Say I have a pt with DM, HTN, Hypontremia, Fatigue, Fever and SOB. What DX do I list 1st?

 

[eadun2000]

Thank you. We use T-Charts at our facility and our Providers do not list in order the Dx codes I need to use 1st. They just write several in the Clinical Impression Box. So I always coded CC 1st and then findings. How do you know which DX code needs to be place above another DX code. Say I have a pt with DM, HTN, Hypontremia, Fatigue, Fever and SOB. What DX do I list 1st?

I would assume that the patient came in for either fever or SOB. Read the record to see what brought the patient to the ED to begin with... what was done... what all was documented?