Diagnosis-If the doc has

[nyyankees]

If the doc has diagnosis codes 719.46 and 719.45 (knee + hip pain) on the claim BUT in his assessment it states patient has torn meniscus can claim be released?

diagnosis codes, diagnosis coding

 

[mitchellde]

In my opinion no, unless you change the code to match the note

diagnosis codes, diagnosis coding

 

[nyyankees]

In my opinion no, unless you change the code to match the note

Thanks. I have always based my auditing on that the dx code (719.46) should be documented in the Plan and Assessment section of the note. Not in HPI or exam. Am I correct?

diagnosis codes, diagnosis coding

 

[mitchellde]

The diagnosis code is based on the entire note. If the assessment states knee pain but the exam is torn meniscus then I code the torn meniscus, if the exam states knee pain ans the final assessment is torn meniscus then I code torn meniscus as the pain is a symptom of the definitive diagnosis. It must all hang together.
Example.. I had one note that stated CC-skin rash
the exam state no rashes or abnormalities and no concerns
the assessment said no issues but the plan indicated a cream for the rash.... WHAT RASH! this note went back to the provider.
The note must hold together not just one piece of it.

diagnosis codes, diagnosis coding