Coding 042 from a CD4 count?

Darren M.

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Good afternoon all. Reviewing our Infectious Disease notes and their documentation for AIDS is very poor at my facility. We're educatiing our providers on the fact that outpatient coders cannot code 042 (AIDS) solely from a documented CD 4 count in their progress notes. The Inpatient Supervisor and some of the providers disagree so I'm looking for a source document to prove our point on the outpatient side.

Can you back me up and send me what ever you have on this issue?
Thank you!

darren.mitzkavetch@va.gov[/SIZE]
 

mitchellde

True Blue
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The lab is reported by lab techs and have no provider interpretation. A coder may code only from provider documentation, a lab value is not the documentation of a diagnosis. Look in the coding guidelines for this.
 

Darren M.

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Thank you. The Infectious Disease providers are asking why can't we code AIDS if they document HIV and document a CD4 count in their progress note. I've explained that coders are NOT clinicians and cannot interpret a lab report. They all seem very apprehensive documenting that the patient has AIDS.
 
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