Wiki Diagnosis coding for hospitalists

[klienhart]

Hi, I'm really hoping someone can give me some insight into diagnosis coding for hospitalists. I am new to auditing. My specialty is orthopedics, but my director has me auditing a Hospitalist coder. I am noticing that she is not coding all of the diagnoses under the Assessment and Plan. For example, the hospitalist documents 10 diagnosis codes, but my coder is only coding 7 of them. I have also noticed that the diagnoses she is Not coding will look like this -

9. Hypertension - continue metoprolol.

Where as the ones she Is coding will look like this -

1. Diabetes Mellitus type II - continue insulin, get an A1c

Basically, the diagnoses she is coding have some kind of further instruction or have a test ordered.

Any thoughts? Is my coder correct in Not coding all of the diagnoses. I do understand that the hospitalist Cannot code for a condition being followed in the hospital by another physician.

TIA

 

[twizzle]

Well, the example you give has HTN in the A/P which is being addressed by 'continue with Metoprolol'. Had HTN been documented without any plan then it's not being addressed. A further instruction or test ordered supports management as does a decision to just continue with a long term medication without further testing.
I think your coder is incorrect to not code these problems - of course, if you meet with the coder post-audit you can ask them for their rationale for coding versus not coding a particular problem. This would be a good enough example.

 

[klienhart]

Well, the example you give has HTN in the A/P which is being addressed by 'continue with Metoprolol'. Had HTN been documented without any plan then it's not being addressed. A further instruction or test ordered supports management as does a decision to just continue with a long term medication without further testing.
I think your coder is incorrect to not code these problems - of course, if you meet with the coder post-audit you can ask them for their rationale for coding versus not coding a particular problem. This would be a good enough example.

Thank you!!

 

[thomas7331]

Agreed, the criteria for reporting a diagnosis is that the condition requires or affects treatment at the encounter, so the hypertension here meets that if the provider wrote a plan to continue the medication.

The coder may be following some more specific internal guideline of the department or organization. If they’re asking you to audit these employees’ work then they should be sharing any guidelines with you so you can audit according to the same policies that the coders are using.