Coding cataract extraction

jgossett

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Franklin, KY
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I have coded cataract extraction for several years, but only until recently, it was the anesthesia support for it. But about 2 weeks ago, I began working directly for the eye docs. The op note they use has "cataract, right eye", or something very similar. Now, all thru the patients' charts will be the specific cataract, but they leave it off the op note. I have been coding H26.9, thinking that I need to code what is on the note. I have explained this to the docs, but so far, no change. Still working on this.

I just got my first Medicare denial because H26.9 does not support medical necessity.

My question is this: Is it ok for me to go back into the patients' charts to get that specific cataract, and code that?

It seems I remember being told that it is not professionally ethical to do that, that each note needs to stand alone.
 
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