Do billed dx codes have to match dx codes on the note?

hperry10

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My organization is working on several risk coding projects. After reviewing the notes we want to add or correct the dx codes on the claims before they are submitted. Our clients want the providers to correct the codes on the note prior to claim submission so the dx codes on the claim match those on the note. We feel that as long as the provider's documentation supports the billed code there is no problem and there is no need to create extra work for the providers. Does anyone have any documentation to support either of these positions? Thank you in advance.
 

sls314

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I agree with you. The important thing is that the documentation supports the code you're assigning.

Personally, I'd prefer not to even see a code by the provider - just state the diagnosis in words and let the coder code.

More often than not, the diagnosis code that a provider assigns is incorrect in some way anyhow. Especially when it comes to combination codes. (For example, you'll almost always see the I10 picked by the provider for hypertension, even if the patient also has CKD. If the assessment clearly documents that the patient has hypertension and CKD, that should be sufficient for the risk coder to use the combination code. You don't need the provider to go back & make a change to the assessment, even if the provider chose the I10.)
 

thomas7331

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I agree also. The diagnosis codes billed do not have to match any codes that happen to be in the medical record. Per the ICD-10 guidelines, section I.A.19, "The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient." Codes must always be based on the provider's written statement. The provider's verbiage in the record is the only information in that a payer can legitimately use to validate the coding of any claims. There is no reason to take up the providers' valuable time by having them amend the records to change codes.
 
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