Wiki Coding Diagnosis From Medical Records

[kathymoon]

We are a physicians group owned by the hospital. We have a coder who bills the professional portion of vascular surgeries. The vascular surgeon placed a chemo port and listed the diagnosis as "unspecified cancer." The coder looked back in the records and found a more specific diagnosis in the Oncologist's records.
She was told by the hospital coders that this was not appropriate, because the performing doctor did not list the specific diagnosis, she could not use the specific cancer (neoplasm) code. So is the hospital correct or can we dig a little deeper and come up with the more specific diagnosis?

Thanks for any feedback.

 

[mitchellde]

Yes they are correct you cannot use information in a previous encounter to code this encounter.