Wiki Diagnosis Codes

[istanstu]

Trying to ease provider burden while our EMR is transitioning thru snomed, we are experiencing lots of tiny discrepancies in what the provider lists in A& P/diagnosis section of chart. Example patient comes in for 3 day routine newborn check-
Sometimes the EMR differs by Invalid Digit child is 3day old well v20.31but EMR populated wellhild check v20.2 is it okay to submit claim with correct age appropriate code of V20.31 without having physician reopen chart and correct diagnosis codes if it can be inferred from charting

 

[mitchellde]

the codes on the claim must come from the documentation. It does not matter if the codes do not match the codes selected by the provider as long as the codes on the claim match the narrative dx in the chart note.

 

[PVAzCPC]

Along the same lines, my provider documented "Significant clinical obesity, especially abdominal" and "Lab results: ......., Vit. D- 30 mg (30-100) Low Sep.'13"

In Assessment, he reported only DM. Because the obesity is documented as clinically significant, and pt is diabetic, and there is a documented (by the provider) low Vitamin D level and he started her on Vit D supplement, can I code and bill for Obesity (unspecified) and Vit D deficiency?

 

[mitchellde]

you can code the obesity but the Vit D is documented as only low and is not sufficient for a dx code of deficiency.

 

[PVAzCPC]

you can code the obesity but the Vit D is documented as only low and is not sufficient for a dx code of deficiency.

Even though he started her on Vit D supplementation?

Thanks for your help as always, you are appreciated!