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coding from chart notes

J

jovibon110@gmail.com

Networker
Messages
61
Location
Kalispell, MT
Our doctors push ICD-10 codes that show up on the chart notes. If he pushes a pain code but the body of the notes state patient has a sprain, etc. I have been coding the sprain or fracture or whatever based on the dictated note not on the code he pushes. ??? Anybody else have issues with this.
 
ICD-10 rules/instructions state that Symptom and Sign Codes (R Codes) should not be used except on a temporary basis and only when and until a more "specific" is made, which should then replace the R Code. Symptoms and Signs are not Diagnoses in and of themselves, and should only be used for as long as it take to make the most specific diagnosis. If the Doctor keeps using the R Code repeatedly for the patient in question, but his "notes" clearly indicate a more specific diagnosis, the the Coder should use the "most specific" code, and the Doctor needs to be informed that his code is no longer correct.
Alan Pechacek, M.D.
 
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