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Wiki Congestion

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nwanczyk

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I was audited on a Labrotory tests (POV's) outpatient with a Basic Metabolic Panel, CBC and Urinalysis. My diagnosis were Congestion/Rales. (I was docked for not putting Chest Congestion). I did not code the Congestion because it did not give me any other diagnosis but Congestion. I do realize the Rales can make a person assume to do it as Chest congestion, but I felt there is more involed with the different test that were done.
Nita W.
 
Being docked for minimal coding.

Hello:

My question is this, why would you not code something that was documented. I am a graduating student from Everest University and one thing that has been instilled in all of the billing and coding students is that if it isn't documented it isn't coded. That was a specific diagnosis, and yes it seems to be a symptom for a condition, however, it was a presenting problem upon the entrance of the outpatient visit. So wouldn't or shouldn't it be coded, the code according to my ICD-9-CM 2010 edition states that the congestion code should have been 786.9.

I am just a student graduating and haven't had any hands on experience yet, because my externship hasn't started, however, I had some very good instructors that have been in this field for many years and I trust their guidence. Another things that stops me from knowing exactly why you are looking at the record this way is because I can't see what you see. Nonetheless, coding for the congestion just makes sense to me, I wouldn't code my diagnosis based on the procedure (Pathology test), I would code according to physician's specification and written documentation, unless other wise informed ( correctly informed that is).
 
I sympathize with you Nita. There are many types of congestion other than "chest congestion". Coders aren't supposed to assume anything. The order should have specified "chest congestion" if that was the reason for the labs. On the other hand I would have suggested that you query the ordering physician about the specific type of congestion so you could assign the appropriate Dx code and not just leave it off.

Eileen
 
junk code for "congestion" is 799.89. I realize it is a junk code, but if it is not documented as nasal congestion, chest congestion, etc. you have no other specific code to use.
 
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