Wiki Can a provider choose his own diagnoses?

bdcoyne8

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Local Chapter Officer
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Idaho Falls, ID
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In our EHR, the provider is able to select his own diagnoses. We are curious as to whether the diagnoses he chooses are what we are able to code off of. I cannot find anything from Medicare stating that this not something the provider can do and we have some in our clinic that believe that this is a part of his medical decision making with the assessment and plan and our billing office states that the provider cannot code their own. But we have a diagnosis calculator so why give them the option to select the best diagnosis code if we can't use it?

Does someone have anything in writing stating that this is not something the provider can do?

The provider chose the M50.123 but there is nothing in his encounter that states the level or the radiculopathy. So I am wondering if it is acceptable to code his M50.123 based on the calculator. If not, please show me why!

Thank you!!

Patient presents to the clinic for follow-up regarding chronic debilitating neck and low back pain. Patient struggles with neck pain which will radiate into her upper extremities. She has significant weakness in her upper extremities. She drops objects, she has a hard time writing and even simple tasks such as taking a cap off of a Sharpie marker can be difficult for her. She has tried and failed cervical epidural steroid injections. She does have some facet arthropathy, however she's hesitant with interventional procedures on her neck. She really does not take much in the way of medication to try to manage her pain. I do recommend that we start her on some gabapentin, however. She is also having worsened low back pain. She has pain noted around the sacroiliac joints. She has a positive straight leg raise and positive facet loading. She underwent lumbar radiofrequency ablation and saw a little benefit from this. She has thus far tried and failed lumbar RFA, cervical ESI's, and reports having some slight benefit from lumbar ESI's in the past. At this point in time, her pain is most notable around the sacroiliac joints with positive sacroiliac joint loading with three provocative tests consistent with sacroiliitis. Concern of the weakness in the upper extremities at this point. She does have disc bulging and central canal narrowing and stenosis in the cervical spine. At this point in time, we will refer her to Dr. A.



DescriptionCodeProblemComment
Other Spondylosis, Cervical RegionM47892
Cervical Disc Disorder At C6-c7 Level With RadiculopathyM50123
Spondylosis W/o Myelopathy Or Radiculopathy, Lumbar RegionM47816
Sacroiliitis, Not Elsewhere ClassifiedM461
 
It may be internal policy that a provider cannot choose his own codes, but nowhere else is it a rule or a policy. In many offices, the provider IS the person who chooses the codes.

If he is choosing a code that is not backed up by documentation, he needs to be education on either documentation or choosing the right code, or both.
 
Our providers all assign their own ICD10 and E&M codes. They have to be educated on how to do it. They cannot select a diagnosis code that is not supported by the documentation. They must narrate their diagnosis in the note and use the narrative to find the code. As any coder would do. I’m an auditor and if it isn’t supported that would be an audit finding back to the MD/APP.
 
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