Wiki Coding for Diagnostic Tests-Need Advice Please!

[gabetteyoung@yahoo.com]

I code for a hospital. We have an orthopedic clinic that routinely sends patients for MRIs. Quite often, the only diagnosis on the order will either be for a complete rotator cuff tear or a meniscal tear - they don't list signs or symptoms or use any type of "rule-out" verbiage. More often than not, when I look at the MRI report it will state "no meniscal tear detected" or "no rotator cuff tear" or possibly "partial rotator cuff tear." When this happens, I usually contact the clinic and ask them to send a new order with signs/symptoms rather than a definitive diagnosis. The problem is that the clinic is using the rotator cuff tear or meniscal tear diagnoses to get the MRI pre-approved, so if the claim is not coded the same as the pre-approval, the MRI is being denied.

I've been told by people higher up the ladder from me (not necessarily coders) that I should code according to the orders which I don't think is correct when I can look at the MRI report and see that it doesn't match the diagnosis on the order. This is a very small hospital where the billing department and the HIM department are very closely intertwined. I understand we want these procedures covered, but I feel they are looking at this strictly from a financial standpoint and I'm trying to make sure I code my accounts correctly.

It seems to me the orthopedic clinic is using the wrong diagnoses to get these tests approved, and because that's the only thing on the order I have no way of knowing whether this is a follow-up for an existing condition or if they are trying to rule-out a new problem. When I bring it up, I'm told to code according to the order. If that's the way it should be done, I'm not sure why we need coders - data entry people would be sufficient.

Am I looking at this wrong or misunderstanding something?? I am not sure how to handle this and any advice would be greatly appreciated.

 

[TThivierge]

Hi Gabette
I d code to the xray order sent to you. Also the medical record documentation of treatment visit probably discusses more info with the patient on rationale to get xray. I gather you do not see the original medical documentation for corresponding treatment in which xray order is given? The provider thinks it might be a tear or rotator cuff problem. He has INDICATIONS this might be happening but not verified till xrayed. And yes if it is pre approved by payer the dx codes need to match. Now it will be interesting to see if there is another problem.so let s say the radiologist find bone cancer or fracture which does not match the original order. Then if an additional dx code of this shoulder problem is discovered on xray results I 'd add it as another dx code .
Id follow management on this issue

Lady T

 

[thomas7331]

I think your instincts and concerns are valid here, but as a coder, my recommendation would be to refer this to your hospital's management or compliance department and follow their guidance. If the outside physicians are indeed giving incorrect codes on their orders, then this could in fact pose a risk to your hospital's revenue in the event that the payers do an audit of the orthopedic offices' records and determine that the services should not have been covered. Those offices should be educated about submitting the codes that reflect what's in their records. But as a coder for the hospital, it's not really up to you to audit each case and second guess what's being sent to you by those outside offices if those records aren't accessible to you as part of your job. I'm sure it cuts into your productivity and unless your employer has asked you to do this, I wouldn't independently make the decision to do so. I would share your concerns with your supervisors and ask them for guidance on how they want you to handle these situations, but ultimately, it's up to your employer as they're the ones who are responsible for their management decisions.

 

[gabetteyoung@yahoo.com]

Hi Gabette
I d code to the xray order sent to you. Also the medical record documentation of treatment visit probably discusses more info with the patient on rationale to get xray. I gather you do not see the original medical documentation for corresponding treatment in which xray order is given? The provider thinks it might be a tear or rotator cuff problem. He has INDICATIONS this might be happening but not verified till xrayed. And yes if it is pre approved by payer the dx codes need to match. Now it will be interesting to see if there is another problem.so let s say the radiologist find bone cancer or fracture which does not match the original order. Then if an additional dx code of this shoulder problem is discovered on xray results I 'd add it as another dx code .
Id follow management on this issue

Lady T

Thanks, Lady T! I appreciate your insight!

 

[gabetteyoung@yahoo.com]

I think your instincts and concerns are valid here, but as a coder, my recommendation would be to refer this to your hospital's management or compliance department and follow their guidance. If the outside physicians are indeed giving incorrect codes on their orders, then this could in fact pose a risk to your hospital's revenue in the event that the payers do an audit of the orthopedic offices' records and determine that the services should not have been covered. Those offices should be educated about submitting the codes that reflect what's in their records. But as a coder for the hospital, it's not really up to you to audit each case and second guess what's being sent to you by those outside offices if those records aren't accessible to you as part of your job. I'm sure it cuts into your productivity and unless your employer has asked you to do this, I wouldn't independently make the decision to do so. I would share your concerns with your supervisors and ask them for guidance on how they want you to handle these situations, but ultimately, it's up to your employer as they're the ones who are responsible for their management decisions.

Thank you, Thomas! I appreciate your insight!