Is this appropriate?

jdibble

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If anyone can answer this it would be great! I code for various surgeons in our practice and never had this issue before. I have a Plastics that I code surgeries for. I get a copy of the OP note and have to code from this. The doctor has been doing breast reductions and in her report she states only the following:

PREOP DIAGNOSIS: Bilateral breast hypertrophy.

POSTOP DIAGNOSIS: Bilateral breast hypertrophy.

PROCEDURE PERFORMED: Bilateral breast reduction.

So I send the billing off for the breast reduction with the dx of Breast Hypertrophy. No specimen was sent to pathology so there is no path report for any further dx. Now her office staff is calling me because they had to get approval for the surgery so it was not considered cosmetic and states that I need to include a dx for back pain or neck pain, or whatever dx she used to get it approved. I told her I can only code with the dx I was given on the OP report. She wants to send me the dx she used for the approval even though it is not listed on the OP report. Is it appropriate to add codes from another source if it is not stated in the OP report that I am coding from? If the insurance requests the report for review, the dx billed will not be there, so is this acceptable?

I appreciate all responses! :)

Thanks,
 

jdibble

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Generally, a patient will have problems such as neck and back pain along with breat hypertophy. It is ok for you to add it if the patient really has it. If there is documentation supporting this then you can use it. I personally would ask for an addendum to the op report documenting the neck and back pain. The doctor is responsible for diagnosing the patient so they should only be adding neck and back pain if there are complaints of this prior to the procedure being performed.
Thank you Mdunn for your response. That was the issue that I had with the OP report - coding by that there is no documentation to support any other dx. The office is saying that they have this info in the patient's chart in the office because that is what they used to get insurance approval, but it is not included in the note that I have to code from. They want to send me the dx to include with my coding. My concern is that if I include these dx's but it is not on the OP report is that allowable - or does it need to be on the report for the procedure to be coded? In the event of an audit, would they disallow these dx's if not on the OP report?

Thanks again.
 

mitchellde

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I answered this in a different post, so just to recap. No you cannot use a dx that is not documented on the operative note. If need be you can include the office notes with the op note for an appeal if it is denied.
 
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