rsadkins
Guest
I am needing some help in convincing a coder it does not matter where in the medical note (EMR) the physician documents conditions as long as he documents what and how he treats the condition/diagnosis.
She says she was told in her ICD-10 training and is convinced that because the physician documents a diagnosis/condition in the "impression & recommendations" (similar to plan or assessment)area of the EMR, the coder HAS TO code this diagnosis. example:
Problem 1 COPD – treated with antibiotic prescription
Problem 2 GERD - treated with PPI prescription
Problem 3 Pseudomonas infection - treated antibiotic prescription as above
Problem 4 Cholelithiasis - as per Dr. Jones
I would code just the first three problems because he treated/addressed those, but I would not code problem 4. It does not matter that it is listed under the "impression & recommendations" area of the record.
If I am wrong, I need to change my thinking. I just do not recall or can find that this type of documentation is an ICD-10 requirement, which is what she is convinced of.
Any thoughts?
She says she was told in her ICD-10 training and is convinced that because the physician documents a diagnosis/condition in the "impression & recommendations" (similar to plan or assessment)area of the EMR, the coder HAS TO code this diagnosis. example:
Problem 1 COPD – treated with antibiotic prescription
Problem 2 GERD - treated with PPI prescription
Problem 3 Pseudomonas infection - treated antibiotic prescription as above
Problem 4 Cholelithiasis - as per Dr. Jones
I would code just the first three problems because he treated/addressed those, but I would not code problem 4. It does not matter that it is listed under the "impression & recommendations" area of the record.
If I am wrong, I need to change my thinking. I just do not recall or can find that this type of documentation is an ICD-10 requirement, which is what she is convinced of.
Any thoughts?
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