Wiki ICD-10 Question

[mizz_emoore@yahoo.com]

My coworkers and I are needing some clarification on if we are allowed to submit a diagnosis on a claim without any literal interpretation throughout the medical record documentation; however at the bottom of the note the provider refilled a medication and pulled the diagnosis header above the refill. For instance COPD is on the claim but no where in the note did the provider document the patient having COPD or anything related to the diagnosis but at the bottom of the note the provider listed a medication with a COPD header. Thank you!

 

[thranowski]

The chief complaint has to match the note. If insurance audited this chart, they would take issue with this. It's a fraud prevention thing. I'd tell the doctor the visit is missing the assessment and the only dx listed is COPD which wasn't what they were seen for and doesn't match the note.

 

[paamstutz]

Hi - with the 2021 Changes to the E/M Office Outpatient codes (99202-99215) my recommendation would be to educate your providers with the actual AMA guidelines which CMS adopted. These guidelines discuss how prior "requirements of CC, HPI, HX, Exam and MDM" have either changed or been eliminated. Both of these links are very helpful. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf I also attached the recent Webinar from Noridian. All discuss when you can count a problem if it was addressed etc. (which would then answer your question about can I code the ICD10-CM code). Good Luck!