Question Coding from the H&P

klightner

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Hello there! I am hoping to resolve an ongoing question between myself and our hospital coder. If a provider doesn't provider a diagnosis or provides a non-specific diagnosis on an operative note, she uses the diagnosis from the H&P as the surgery diagnosis. As for me on the professional side, I am under the impression that I cannot do this and that the operative note has to stand on it's own. The previous professional coder used the H&P diagnoses as well in these situations but I don't feel that this is the right thing to do. I feel like I should be querying the provider to get the correct diagnosis on the procedure note.

Any information on this and/or a professional source I can reference would be wonderful!
 

csperoni

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Orthocoderpgu

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I agree with Christine. But also keep in mind that the pre-op diagnosis and post-op diagnosis are two different things. If your coding for the provider you should be looking at the post-op diagnosis or diagnosis that is in the body of the op note. The pre-op diagnosis changes since the provider can be more specific after the surgery. This is true in orthopedics anyway. The other coder seems to have been cutting corners to get the work done. I have followed coders like that and that's when management has discovered issues that they were not aware of previously.
 
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