Wiki Coding dx from H&P

[belindapearl]

Can anyone tell me if it is okay to code a diagnosis from the H&P if it is not listed on the op note? I am coding the opertative procedure for the physician and I noticed that our coding company (who codes for the hospital) pulls diagnosis from the H&P that is not listed on the op note.

 

[mitchellde]

Can anyone tell me if it is okay to code a diagnosis from the H&P if it is not listed on the op note? I am coding the opertative procedure for the physician and I noticed that our coding company (who codes for the hospital) pulls diagnosis from the H&P that is not listed on the op note.

No this cannot be done. The op note must speak for itself. And what would be the motivation to this anyway?

 

[BenCrocker]

Laziness clearly with the EMR on the hospital side.

 

[bethh05]

I don't think it is always laziness, some of the physician's where I am employed do not dictate pre or post op diagnosis sometimes, and they do not answer my queries 80% of the time. I know the medical record needs to stand on its own, but isn't the H&P part of the patient's medical record? I found this on For The Record:
Every record has to stand on its own individual merits. Before a condition can be coded, it must meet two requirements. One, the condition has to be documented by a physician in the body of the medical record, such as history and physical, consultant report, progress notes, or discharge summary. The second requirement is that it must affect patient care in terms of requiring one of these five criteria: clinical evaluation, therapeutic treatment, diagnostic procedure, extended the length of hospital stay, or increased nursing care and/or monitoring

 

[mitchellde]

An operative note is its own record the diagnosis that is the reason for the procedure must be on the operative note. You cannot use the H&P for the diagnosis for the procedure. I have never had a operative that did not have the diagnosis somewhere within the procedure note.

 

[dakotahgrefsrud]

An operative note is its own record the diagnosis that is the reason for the procedure must be on the operative note. You cannot use the H&P for the diagnosis for the procedure. I have never had a operative that did not have the diagnosis somewhere within the procedure note.

My providers are asking for supporting documentation to back this up as we're getting kick back. Do you know where I can find that information? I'm having a hard time digging it up.
Thank you!

 

[fwnewbie]

I've been a nurse for 30 years and any op note I've ever seen has a distinct pattern with a heading section listing pre/post op diagnosis. You code from the post op dx if it's different from the pre-op. ie an unexpected finding during the procedure that impacts the dx.
Someone in medical records needs to sit on this get results imho.

 

[katemae84]

It's in the CMS State Operations Manual, Appendix A, Survey, Protocol, Regulations and Interpretive Guidelines for Hospitals, which can be found here.
Under the CoP for Surgical Services, see section A-0959 for CMS's interpretation of regulation 482.51(b)(6) that says the Op Note must contain at least:
• Name and hospital identification number of the patient;
• Date and times of the surgery;
• Name(s) of the surgeon(s) and assistants or other practitioners who performed surgical tasks (even when performing those tasks under supervision);
• Pre-operative and post-operative diagnosis;
• Name of the specific surgical procedure(s) performed;
• Type of anesthesia administered;
• Complications, if any;
• A description of techniques, findings, and tissues removed or altered;
• Surgeons or practitioners name(s) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner (significant surgical procedures include: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues); and
• Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any.