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Wiki Can you pull dx from the H&P when coding pro fee outpatient surgeries?

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mmelough93

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I thought the op note had to stand on it's own, but have been advised by management it's okay to use the H&P to determine dx. I work for a big health system and sometimes provider documentation isn't the greatest (for example- many providers will put dx on the op note for colonoscopy as screening, however looking at the H&P they have bleeding or history of polyps which wouldn't be a true screening). Does anyone have any references or resources to support one way or the other?
 
Yes we can always correlate the diagnosis with H&P to decide on the coding especially diagnostic and screening colon. Even if symptoms are documented in the H&P need to make sure if its incidental or current patients problem.
 
You could use it as a reference, but in my opinion you cannot report the diagnosis code directly from the H&P only. The (outpatient) operative report must contain the diagnosis and that is what must be coded. The op report has to stand alone. The H&P is a snapshot in time of the medical history and physical PRIOR to surgery occurring (sometimes 30 days prior). How can you use a diagnosis that was documented earlier than the date of service you are coding (outpatient)? The H&P is medical evaluation to determine if the patient is healthy enough for surgery.


This is from the State Operations Manual Appendix L regarding ASC: Interpretive Guidelines: §416.47(b) " • An operative report that describes the surgical techniques and findings." https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf

This is State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals: A-0959 §482.51(b)(6) - An operative report describing techniques, findings, and tissues removed or altered must be written or dictated immediately following surgery and signed by the surgeon. The operative report includes at least: • Pre-operative and post-operative diagnosis;

Further, if the payer requests medical records and you try to send the H&P as supporting documentation for the diagnosis and it doesn't match the operative report, they are probably going to deny it or at least have a finding for it.
 
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