Wiki General Question

[cgates1976]

I just have a general question. When you're coding and say the provider coded unspecified knee pain but the note clearly says right knee pain. So instead of me removing the unspecified code and adding the M25.561, our providers have told us we have to ask them if they will allow us to change a code. We cannot even remove a code from a claim without asking even though there's no documentation/treatment/assessment of any kind on the note. I was just working on a claim where the patient was here for her annual physical. It clearly says in her note that she has a personal history of cervical cancer but the code was not added nor put in the patients problem list. As a coder, I thought we were able to add those codes? Isn't that the reason we got certified? Please correct me if I'm wrong. I feel as if our providers doesn't trust us to choose the correct codes.

 

[bgrasson]

I just have a general question. When you're coding and say the provider coded unspecified knee pain but the note clearly says right knee pain. So instead of me removing the unspecified code and adding the M25.561, our providers have told us we have to ask them if they will allow us to change a code. We cannot even remove a code from a claim without asking even though there's no documentation/treatment/assessment of any kind on the note. I was just working on a claim where the patient was here for her annual physical. It clearly says in her note that she has a personal history of cervical cancer but the code was not added nor put in the patients problem list. As a coder, I thought we were able to add those codes? Isn't that the reason we got certified? Please correct me if I'm wrong. I feel as if our providers doesn't trust us to choose the correct codes.

I REMOVE/CHANGE CODES ALL THE TIME. THE DOCUMENTION SUPPORTS IT. WE WOULD NEVER GET ANY CLAIMS OUT SINCE PROVIDERS DID NOT RESPOND WELL.

 

[carlystur]

I agree with you. You might ask your manager to chime in and hopefully back you up regarding this. If your providers don't want you to code from their documentation, then what were you hired to do?

 

[sls314]

I just have a general question. When you're coding and say the provider coded unspecified knee pain but the note clearly says right knee pain. So instead of me removing the unspecified code and adding the M25.561, our providers have told us we have to ask them if they will allow us to change a code. We cannot even remove a code from a claim without asking even though there's no documentation/treatment/assessment of any kind on the note. I was just working on a claim where the patient was here for her annual physical. It clearly says in her note that she has a personal history of cervical cancer but the code was not added nor put in the patients problem list. As a coder, I thought we were able to add those codes? Isn't that the reason we got certified? Please correct me if I'm wrong. I feel as if our providers doesn't trust us to choose the correct codes.

Laterality is absolutely something that you should be empowered to correct when supported by the documentation though. That's literally a coder's job!

Does the provider truly want to be bothered every time something minor like that comes up? Do they realize that payers will often deny claims with those unspecified laterality codes?

Why would the provider want the claim to go out with "unspecified knee pain"? Surely they know which knee they examined!

As just one payer example, starting 8/1/2023, Anthem has begun denying claims for unspecified laterality, if a more specific code should be documented and used: https://providernews.anthem.com/kentucky/articles/unspecified-diagnosis-code-of-site-and-laterality

I'd talk with your manager about how they want you to handle it.

If I were the manager and the providers wouldn't budge, I might keep a log of all the claims being held up for minor coding issues, and send it to them weekly. Once they see the unreleased claims start building up, that might be what they need to implement a more reasonable code correction policy.


(The personal history of cervical cancer may not necessarily needed to be added to the claim for a PCP's annual physical if the provider didn't address it anything related to it. However, if it was an annual well-woman exam, I'd include the personal history of cervical cancer, because it is relevant to that type of exam. I wasn't clear which type of physical might have been happening in your example.)

 

[csperoni]

I agree with everyone else that a coder is certainly qualified to take the words in the medical records and assign codes to them. However, there are some employers who will not permit their coders to do so unless the physician is aware or updates the EMR. For those employers, I can only assume that decision was made by someone who does not understand coding.

No, a coder cannot assign E11.65 (DM II with hyperglycemia) simply because they see a finger stick result of 210. A coder is absolutely trained to assign a code to the words in a chart. I think of coders like translators. No, a translator should not infer and translate "I love you" if the original statement is really "I care about you deeply." If a phrase or word could have multiple meanings then a translator could ask for clarification (just like a query to a clinician) in order to accurately translate. But if the note clearly states pain in the right knee, there should be no reason a coder cannot assign the correct ICD10 for that.