jlbarbour
Guest
When using an EHR the providers search for the diagnosis either by description or code. The code selected in the EHR is connected to diagnosis description. The code automatically goes to the Practice Management system, but the Practice Management System diagnosis description may differ from the EHR. Practice Management uses CMS ICD-10-CM Code Set.
Example:
In EHR M89.8X1 description = Pain of right scapula
In PM M89.8x1 description = Other specified disorders of bone, shoulder
Medical documentation states:
"Was mowing.....going down a hill. Accidentally hit accelerator instead of brakes.....hit tree with mower head on. He was ejected.....not sure if he struck the tree. Doesn't remember how he landed. Had instant scapular pain.
Patient is an employee of XXXXXXX. Fell off of a mower and hit a tree this morning. Pain is located in right shoulder, posteriorly. Denies any other injuries.
( I do not agree with the selected code, but the question is related to descriptions)
QUESTION: Must the diagnosis descriptions in EHR match the PM or as long as the medical documentation supports the code is it alright to have different descriptions for the same code?
Example:
In EHR M89.8X1 description = Pain of right scapula
In PM M89.8x1 description = Other specified disorders of bone, shoulder
Medical documentation states:
"Was mowing.....going down a hill. Accidentally hit accelerator instead of brakes.....hit tree with mower head on. He was ejected.....not sure if he struck the tree. Doesn't remember how he landed. Had instant scapular pain.
Patient is an employee of XXXXXXX. Fell off of a mower and hit a tree this morning. Pain is located in right shoulder, posteriorly. Denies any other injuries.
( I do not agree with the selected code, but the question is related to descriptions)
QUESTION: Must the diagnosis descriptions in EHR match the PM or as long as the medical documentation supports the code is it alright to have different descriptions for the same code?