Coding from documentation not in the delivery summary

dballard2004

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I'm looking for information on if it is acceptable to use documentation not in the delivery summary for billing dx codes. Example: delivery note only states 2nd degree laceration, but doctor bills with DM, which is stated elsewhere in inpt record, but not on delivery note? Can anyone point me to any official written guidance on this? Appreciate your assistance. Thanks.
 

Kris Cuddy

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Dawson,

Might you please give some insight into how the delivery summary is stated?

Also, is the provider not the one, or one in the group, who provided antepartum care?

Kris
 

dballard2004

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The delivery summary states that the patient has a 2nd degree laceration. There is nothing in the summary regarding DM, but we billed for this. The DM is mentioned else where in the record not in the deleivery summary.
 

Kris Cuddy

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Dawson,

For me to be able to answer, I really do need to know if the delivering physician is the same physician who did the antepartum care. I know the hospital gets a copy of the patient's antepartum record prior to them being admitted for delivery, and with that a delivering provider ought to be aware that the patient has DM. The DM could complicate the delivery, with the mother's sugar levels needing to be watched.

Also, when you write, "the doctor bills with DM", do you mean the doctor listed DM as one of the diagnoses to be billed for the delivery?
 

dballard2004

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The delivering physician is not the same one who handled the antepartum care. The diabetes is not listed anywhere in the delivery summary, it is listed elsewhere in the antepartum record, but the physician said to bill with it.

I am sorry for not completly answering your question earlier.
 

Kris Cuddy

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Based upon the physician just saying to bill with it, even though it's a part of the patient's record, the physician who delivered needs to provide documentation that this affected, or was a co-morbidity to, possible outcomes of the delivery.

ICD-9 2008 Coding Guidelines advise that, "Diabetes mellitus is a significant complication factor in pregnancy. Pregnant women who are diabetic should be assigned code 648.0X, Diabetes mellitus commplicating pregnancy, and a secondary code from category 250.0X, Diabetes mellitus, to identify the type of diabetes. Code V58.67, Long-term (current) use of insulin should also be assigned if the diabetes mellitus is being treated with insulin."

Gestational diabetes is different with different codes. ICD-9 Coding Guidelines does also offer guidance on that.

With that being said, and this is just my two cents, I'd ask the delivering physician to addendum the delivery summary to include the diabetes condition as a complicating factor, as well as whether it was gestational or not to assist you with coding appropriately. From a legal standpoint, each chart note must stand alone. If the delivery summary were to be submitted to a carrier, or be reviewed by an attorney at OIG, there would be nothing to support DM at all.

Hope that helps.
 
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