CPT specific order

aces78rp

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I know this answer but I need cofirmation from my peers. Can we change a code from the provider to be more specific? Example the provider gave me the code for pain in limb and I read the notes and the pain is in the shoulder area and then he coded chest pain for pain in the ribs. Any response would be appreciated.
 
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cedwards

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I would go to the doctor ICD-9 code book in hand and explain to the doctor which codes I think it should be and explain to him/her why I believe they should be these codes based on the documentation. A lot of times the providers are not aware that their is a code as specific. It goes back to provider eduation. I have instructed my providers to hand write the diagnosis for me instead of circling them on the encounter so we can code it to the highest level of certainty. At the end of the day it is the provider's decision as to the codes selected. If the provider does not want to change the codes I would document that somewhere and have the provider initial it so this way it doesn't come back to you.
 

007CPC

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I’m in concurrence with Christina,
As a prior production coder, who never had luxury of networking with the provider for whom one coded, the code selection was based on what was substantiated at the time of the coder - dictation encounter. If your provider is coding a symptom that never occurred in the Chest vs. a symptom that is substantiated as the purpose behind patient clinician encounter, code the pain in the shoulder; It would be considered as I refer to BUCK RULE #1 if the physician didn’t substantiate, it never happened. Your provider could also be guessing of the top of his head to "what code" is pain in the shoulder, and that is why he has you. It happened to me all the time back in my coding days!
 
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