Wiki Clinician writing DX Code instead of descriptive text on the anesthesia records

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millie362

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Any guidance regarding this issue Clinician writing DX Code instead of descriptive text on the anesthesia records. Would you count this as an error on the audit and educate the clinician to write a descriptive text?
 
Yes, I would consider it an error. A code is not a diagnosis, it is a classification of a group of related diagnoses. ICD-10 guidelines state that code assignments must be based on a physician's statement of the patient's condition. Without a verbal statement in the record, there is no way to conclusively know what the actual diagnosis is, and also no way to validate whether or not the code that was chosen is correct.
 
I've been coding anesthesia for over 8 years. Please know that most often anesthesia providers have a difficult time obtaining diagnosis information. I've spoken with a lot of anesthesiologists and CRNAs to gain knowledge about their processes while on a case, so that I could have realistic expectations. Many told me they get what they get. Often times they're only provided with a code.

That said, talk to your providers to see if it's possible for them to get the diagnosis as opposed to the code.
 
LisaAlonso23 said:
I've been coding anesthesia for over 8 years. Please know that most often anesthesia providers have a difficult time obtaining diagnosis information. I've spoken with a lot of anesthesiologists and CRNAs to gain knowledge about their processes while on a case, so that I could have realistic expectations. Many told me they get what they get. Often times they're only provided with a code.

That said, talk to your providers to see if it's possible for them to get the diagnosis as opposed to the code.
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Good point Lisa. I wonder, if the anesthesia record is housed within a shared record such as the hosital record, could that be used? Could it be pulled from an operative report provided the anesthesia provider has access? I am guessing probably not and many practices have access issues I'm sure. If they are only provided with a code, they could at least convert that code to words and dictate that instead, couldn't they?
 
amyjph said:
Good point Lisa. I wonder, if the anesthesia record is housed within a shared record such as the hosital record, could that be used? Could it be pulled from an operative report provided the anesthesia provider has access? I am guessing probably not and many practices have access issues I'm sure. If they are only provided with a code, they could at least convert that code to words and dictate that instead, couldn't they?
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The anesthesia record is recorded in real time and then they are gathered at each facility to transport to their billing office. However, Op notes are completed well after the procedure and are not available immediately for the anesthesia providers to extract information from.

They often don't know the exact diagnosis and just write down the code they're provided which is sufficient. I would not ask them to convert the code to written word, as many have no knowledge of coding based on my conversations with them.
 
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