Wiki Getting Dx codes corrected on a record

dkaz1

Guest
Messages
84
Best answers
0
Hi there: I really need some assistance with this issue. My honey had a NSTEMI a couple of weeks ago. I went with him for a followup visit at the cardiologists office and we had a list of questions to go over regarding the outcome of the procedure, meds, etc. I asked the cardiologist when he entered the femoral artery to do the cardiac stenting, did he see anything traveling up the aorta? He said no, as he didn't have the camera on and squirted the dye once he was up to the heart over the arch. He asked why--I stated that my honey's dad had both a thoracic and aortic aneurysm. He looked shocked and then grabbed a piece of paper and started checking off items. We got a copy of the physicians order and it was for three separate diagnostic tests--US of the Abdomen, US of the Carotids and a ECHO (color flow & Doppler) with a preprinted dx checked off of 785.9 for Carotid Bruit, 441.4 for Abdominal Aortic Aneurysm w/o rupture and 794.31 for an abnormal AUC. The kicker here is I was present when my honey was seen by the cardiologist, he never checked the carotids with a stethoscope to determine a carotid bruit and there is no abdominal aortic aneurysm. How can I get this information deleted from my honey's medical record? The reason for the studies order should have been Family History of AAA--V17.49. Can anyone suggest how would I get this information corrected on my honey's medical record?
 
SV

Hi there. I am wondering if your husband's physician had wrote that down as a "rule out dx". If that's the case, all of those tests should have been ordered due to family history of those conditions , using the "v" code. In our practice, the coders are instructed not to use "rule out" dx as the final assessment Icd-9 code. So if the physician's MA has ordered those tests using anything else beside the "family history" Icd-9 code, that would not be appropriate. I would contact the office and check with them first. If documented correctly by the physician, your husband's record should support dx change and the office should submit corrected claim to the insurance company.
 
This scenario has nothing to do with the office coders, unless the lab/rad work is being done right in the office setting (unlikely). Typically, patients go to a hosptial or outside lab to have their diagnostic workup done. With that, outpatient lab/rad coders are not allowed to code "rule out". So if coding from an order (and in the case of the US, the results) they would code the disease. Outpatient lab coders in the facilty don't code based off ordering physician documentation (they ususally don't have it). They code off the order alone.

I'd contact your honey's physician and ask him to place an addendum in the medical record indicating that he is revising the order due to an error in diagnosis ordering and then have the office provide you with a corrected order.
 
Last edited:
Top