Wiki DX Quandry

[Peter Davidyock]

I find myself between a rock and a hard place.
I have in the past coded pain management, general practice, ent and a few other things.
Now I am coding anesthesia.
Here is my problem: The person I am responsible to is instructing me to code from a schedule and not from a op report.
Let's say an op report reflects Hx of polyps as a pre-dx and the post-dx is diverticulosis but the schedule says the post-dx is hemorrhoids. Now hemorrhoids does not appear anywhere in the 3 page op report, only on the schedule. I am being instructed to code the hemorrhoids from the schedule as the post op dx.
It's really bothering me. Am I wrong?
Everything I have learned thus far preparing for the CPMA exam is telling me that coding from anything other than an op report is a slippery slope.
Please Help.

 

[mitchellde]

You would never code anything that is not documented. The schedule is not part of the documentation and someone could have inserted the wrong dx on a schedule. The op note is what the physician renders as the dx at the time of the procedure. If the patient did not have hemorrhoids, you cannot give them to him/her. If the dx of diverticulosis leads to further testing and treatment, it may not be approved because you do not code it initially.