Wiki DX documentation

[kmorga]

At my last job I was taught that the DX does not need to be listed in numeric form in the chart note such as 250.00. Rather if the DM is documented in words we can select the appropirate code and bill for it. At my current job I am being told the provider must indicate in numeric form the DX before you can use it for billing. Can anyone tell me which way is correct?

 

[bforr]

I have never heard that the numeric code must be in documentation. If that were the case, why would the doctors need coders?

 

[ollielooya]

Maybe your current practice requires it for the convenience of those who do the billing?

 

[rmwinder]

No, no, no... The opposite is true. The doctor has to state in words what is wrong. You, as the coder, picks the correct code. He may write down the wrong code. This is a recurring theme I've been noticing. I looked up some backup for it the last time. Can't remember where I found it, but it said that the doctor should never use the actual codes as opposed to verbiage. One of the points was he needs to use descriptive terms, such as...worsening, mild, metastatic, etc. and that just putting down the code and its description was not acceptable. That's one reason we aren't to code from superbills. For instance what if the patient had hypertension and CKD III. The doctor writes down 401.9 and 585.3. That's incorrect. It's 403.90 and 585.3. Just one example.

 

[mitchellde]

The resource you seek is AHA coding clinic 1st quarter 2012 and has been referenced in several posts in the forum. It states that the provider is not allowed to use the code as a substitute for the diagnosis that must be rendered in their own words. Even if a code is indicated it still is up to the coder to read the note and select the correct code. The code selected for the claim does not need to match the code selected by the provider, but must match the narrative diagnosis in the note.