Question Coding from Op note Post DX or H and P

michelleholt

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Hello,
I work under Practice Management for Facility in Central New York. We code the Pro Fee side for our Providers while RI codes the facility side. There has been much debate over where you code for our surgeries.
On the Pro fee side, we are stating that you code from the Post Op dx, Procedure, Indication, and the Body of the Op note along with Path and findings. RI is telling us to code from the History and Physical which can be done 30 days ahead of the surgery. This is not making any sense to us and would like someone else opinion on the topic.
Thank you ahead of time for your input.
 

Orthocoderpgu

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I don't agree with that assessment at all. I have been coding surgeries for several years and I can't tell you how many times the actual diagnosis has changed once the surgeon was able to actually see what was going on. The H&P was documented when only diagnosis tools were X-rays, MRI and CT scans. While these are excellent and provide useful information, they don't always provide a clear picture either. Every time a surgeon performs surgery the first thing that they do is confirm everything before starting any work. The actual diagnosis will come from the post-op diagnosis and body of the op note. Anything prior to that is just a guess which is not confirmed.
 

csperoni

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100% agree with Orthocoderpgu. I only code pro fee, and never facility.
Code from the op note, and not the H&P. That would be like saying to use the CPT code for the surgery you planned, instead of the surgery you actually did.

In fact, there are even situations in which the only way to correctly code is to wait for the pathology afterwards (skin lesion excisions come to mind).
 

jtwskates

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Are they asking you to code from the H&P for additional DX, medications, family HX, etc. We do that on the facility side. We are told to pick up all DX possible. Now, the procedure...that should be done from the Op note and pathology-agreed.
 
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