Question Coding for hospital lab; orders with missing dx

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Hello, trying to find an answer or direction. Our hospital gets lab orders from local providers. Some come with only dx descriptions, others come with only ICD-10-CM codes, others have both code and description. But sometimes they do not provide correct dx codes.

Order came in with "D63.1, I10" on the order. Since D63.1 cannot be primary, but I do not know what CKD to use (N18._), do I just code N18.9 or instead just use D64.9?

My initial thoughts are just code N18.9 since the provider is indicating the patient's anemia is due to CKD and I just don't have documentation to determine anything other CKD NOS but also don't know what the guidelines are to adding dx codes the order/provider didn't provide.

Appreciate it!
 
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thomas7331

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Just my own thoughts here, for what they're worth - it's never a good practice to start guessing or making assumptions about what a provider 'meant' by a particular code. I'm always reminding people that a code isn't a diagnosis, it's a classification of conditions. So to try to work backwards from an incorrect code assignment without having access to documentation will inevitably lead to errors as there's no way to conclusively say what a provider really intended by giving you that code. In the example you give, for instance, you know that the coding is wrong, but you don't know if the provider just omitted the CKD code, or if they selected the wrong code for the anemia altogether. Also, you don't know if the documentation reflects that hypertension is or is not related to the CKD, or whether there is heart failure involved as well, so you'd need to make a second assumption about whether or not to keep I10 or change it to an I12 or I13. In my opinion, just too many guesses involved in a situation like that. You might guess right some of the time, but if you get in the habit, you'll eventually be assigning codes that don't belong to the patient.

If you don't have access to the ordering providers' documentation, your hospital should have a process for querying providers when the order documentation is unclear or incorrect. I believe many will do this by phone and keep a record of the calls, and this is generally considered a compliant practice. This certainly can be time-consuming and cut into your productivity, but it's the right thing to do. (One of my hospital's leaders used to always that that if you don't have time to do it right, how are you going to find time to over again?) For providers that frequently send orders with errors, it might be worthwhile for someone to initiate some kind of training with those offices to try to help reduce the administrative burden they are creating.
 

OpenClaims

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Hi Caleb,

I would never advise to code based from a guess or unclear information. I think the best thing to do here would be to send a query asking for diagnosis clarification. I would not simply ask for the level of CKD, as that would be considered leading since the diagnosis isn't already presence, even though it's clearly known that you need it.

I would say something to the extent of, "Please provide diagnosis clarification for lab XXX."
 
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