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Coding from the Medical record

christine_cornforth

Contributor
Messages
16
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0
Is it appropriate to add additional DX codes as I am reviewing a patients' note for coding purposes? Ie: our practice uses an EHR system, Dr. sees pt and thinks they have a MMT, so he codes it as the tear (not supposed to, I know!) and says that he is sending them for an MRI to rule out. I review the note, I see that the patient presents with knee pain, I want to use the knee pain DX in lieu of the tear that is not confirmed, but the DX of knee pain is not noted under the A&P.....can I add that to the billing based on the patient presenting with it, or do I have to have the Dr. addend his note to include that DX under the A&P?
 

rlh27

Networker
Messages
47
Location
Montgomery
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Does he state in the ROS that the patient has knee pain. Or in the HPI?

You can pull diagnosis codes from other areas of the note.
 

Dorthi

Networker
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66
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Coding from the notes

You have to be careful when hey are doing test to R/O something and it states that in the note, you would be better off to question the Dr on the pain have him do an addendum to the note stating there is knee pain until the there is a definite Dx to code.

If it state knee pain anywhere in there you can use it. But really until there is a DX for the knee pain you cannot use a DX if it states there is a test to determine the DX. Or id it says R/O or if it says a dx vs another dx.

Hope this helpful!
 

christine_cornforth

Contributor
Messages
16
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Does he state in the ROS that the patient has knee pain. Or in the HPI?

You can pull diagnosis codes from other areas of the note.
He does state the patient presented with knee pain. I have battled with this provider to stop coding tears thatt are not confirmed, and keep asking him to addend the note with signs and symptoms, but he is very resistant. This is why I ask if it's appropriate for me to code knee pain without it being under his assessment and plan as an actual dx.
 
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