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Wiki Documentation question
- Thread starter mdm58
- Start date
mitchellde
True Blue
No you must go with what is documented by the provider that performed the procedure as the reason for the procedure.
mitchellde
True Blue
How could she even possibly think this was correct or allowed? The provider that performed the procedure may also have an issue with this. This is not a game of pick and choose.
FTessaBartels
Guest
Pathology report?
The only time this might be done is when you have removed a lesion and must wait for pathology report before coding. In that case the surgeon who removed the lesion might not have specified "carcinoma" while the pathologist report would give a definitive diagnosis.
Other than that example, I can't think of any case where you would change a Dx code to reflect what a different physician had documented.
That being said ... I recently had a near miss. The doctor's operative note listed a diagnosis of choriocarcinoma. When looking at other documentation I noted that all other reports listed chorioangioma. I queried the provider ... turns out it was a transcription error (I listened to the dictation and he had clearly stated chorioANGIOMA)! Good thing I asked before I coded - and the provider DID correct the documentation.
Hope that helps.
F Tessa Bartels, CPC, CEMC
The only time this might be done is when you have removed a lesion and must wait for pathology report before coding. In that case the surgeon who removed the lesion might not have specified "carcinoma" while the pathologist report would give a definitive diagnosis.
Other than that example, I can't think of any case where you would change a Dx code to reflect what a different physician had documented.
That being said ... I recently had a near miss. The doctor's operative note listed a diagnosis of choriocarcinoma. When looking at other documentation I noted that all other reports listed chorioangioma. I queried the provider ... turns out it was a transcription error (I listened to the dictation and he had clearly stated chorioANGIOMA)! Good thing I asked before I coded - and the provider DID correct the documentation.
Hope that helps.
F Tessa Bartels, CPC, CEMC