Wiki Coder staging

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bmohr

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I work in a small privately owned practice. Our coding department was recently asked to start staging Oncology patients to save time for providers, but we don't feel it falls under the scope of coding since we are not clinical. Any body else have any experience with this or any examples of how their offices operate?

Any input is greatly appreciated!

:)
 
to stage a patient based on their neoplasm and clinical criteria is way outside a coders scope of responsibility. Even with a tool it is something that should not be done as you are not clinical personnel and you do not have the education to make diagnostic decisions. This is something that is most definitely a physician responsibility thing. I code path reports also and never are we allowed to determine the stage of a neoplasm it must be documented.
 
Coder Staging

I must Agree that making that type of diagnosis judgement is out side of our scope of practice unless the guidelines direct you; for example DM diagnosis without the type documented in the chart will require us to default to DM type 2 codes. I would have a talk with your supervisor it could be a teachable moment for the providers.
 
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