coding to highest degree

busydawnis

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My supervisor has informed us that we must code to the highest degree. She does not want any unspecified codes used. Our physicians that are seeing hospital based patients are so general, they do not give much detail to the diagnosis code. Many times there is no other specific information to use a more specific diagnosis code. What am I to do if documentation only meets the unspecified code and nothing more specific?

Thank You
:confused:
 

AYCPC

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Unspecidfied codes

You can query the physician to get more information. Also, remember if it is an inpatient chart you can code symptoms. Hope this helps!!

Amanda Yarber,CPC

****If your company does not already have a process for querying physicians let me know and I can get you some material on that.
 

007CPC

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My supervisor has informed us that we must code to the highest degree. She does not want any unspecified codes used. Our physicians that are seeing hospital based patients are so general, they do not give much detail to the diagnosis code. Many times there is no other specific information to use a more specific diagnosis code. What am I to do if documentation only meets the unspecified code and nothing more specific?

Thank You
:confused:

Remember the Golden Rule. It might save you in the long run.
 
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Coding for physician or facility?

Are you coding for the physician or for the facility/hospital?

If your supervisor does not want to see "unspecified" codes, then some education of the physicians is in order. You can only code what they have documented.

F Tessa Bartels, CPC, CEMC
 
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