Wiki Diagnosis Coding Physician and Hospital Difference


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I work in an independent solo practitioner's office. Our doctor does stress test, echoes for the hospital and we will for the professional component. We have a problem.

The stress test A report reads :

1. moderately enlarged left ventricle with calculated LVEF of 45%
etc etc

Another report B reads:
1. mildly dilated left ventricle with end diastolic volume of 128 mL.

Hospital coded both as cardiomegaly I51.7

We have clarified with our physician and he said the patient A has cardiomyopathy (he has seen this pt in the clinic).

We have had cases where it says,
1. fixed perfusion defect was seen involving mid inferior wall, may be due to attenuation artifact. (hospital coded it as cardiac septal defect).

We are concerned for our patients who gets tagged with cardiomegaly and eventually if they have hypertension coded, we have to code them as hypertensive heart disease. We have had cases of patients coming to our office upset that they cannot obtain life insurance, health insurance, coverage etc. due to having serious heart issues.

My question is :
Does the insurances "match" what the hospital and the doctors code? Because if they do, we won't match well.
We are worried about defending our codes during audits.

Thanks for your advice.
You bring up a lot of good points in this post - here are some of my thoughts:

To start with your question - payer may 'match' hospital and physician coding, but when they do this they're usually looking for possible fraud or incorrect coding that is causing overpayments, so you would really only be at high risk if you're changing a diagnosis from a non-covered code to a covered code to get payment. That said, if the codes don't match then someone is probably doing something incorrectly

In theory at least, hospital and physician records should be coded the same way if you're looking at the same record and both coders are following the same guidelines. Based on the info you've given, it sounds like the hospital is doing this correctly - ventricular enlargement or dilation does direct to cardiac hypertrophy in ICD-10. If you are querying the physician to get better accuracy but that information is not being documented in the shared record, then your codes won't hold up in an audit - you can't code from MD 'clarification' (unless they amend the medical record, in which case the hospital would also be responsible for correcting their coding).

My guess is, though, that the documentation is correct here and a physician would probably not amend it. In the interpretation of the test, physicians will only document what they see in the images and won't assign a clinical diagnosis in the report - that is done by the provider who is treating the patient when they take the information in the test and put it into context of the patients entire medical history.

I think it's good to be concerned about the patients' potential consequences in the accuracy of the diagnosis. In cases where the physician documentation is incomplete or potentially incorrect for coding purposes, it's important to be alert and query the physicians, to make sure records are correct and to educate them to improve documentation so that the coding can accurately reflect the patient's conditions.

At the same time, if the documentation is accurate, the coder's goal should be to ensure that the codes reflect what's in the records and not to second guess how the payers are going to use that information. Payers do make errors in their interpretation of what codes mean, or use the information in ways that we may not like or approve of, but we can't take on trying to be responsible for that or let it affect how we code. But we may in a position to use our understanding of coding to help patients resolve issues in these cases by assisting them in the appeal process.

There may be other angles on this and I'll be interested to hear other coders' input.