Wiki Looking for opinions on how to handle erroneous code selection through EMR

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PVAzCPC

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Good afternoon;

I am just wondering how everyone else handles the issue of providers who choose incorrect diagnosis codes through the EMR system.

Perfect example, I just came across in a chart note from October 2015: "Assessment: 1. Neoplasm of uncertain behavior of right kidney-D41.01(Primary)", then, in this EMR the next section is "Plan: 1. Neoplasm of uncertain behavior of right kidney" and under that "Notes: 4 cm right adrenal mass noted on CT in ER....." and then some orders.

So, as coders, we know that "neoplasm of uncertain behavior" is used by the pathologist who cannot determine, with certainty, whether or not the cells or malignant. Since the provider is the PCP, not a pathologist, and he is just commenting on the "mass" noted on CT scan, and ordering further work-up, I feel this should be reported with a N28.89 that is found when searching for "Mass,Kidney".

It's obvious to me that my provider just chose the wrong numerical code, as his free text note states "adrenal mass", not neoplasm.

Thanks for any and all thoughts!
 
You would code based on the narrative note. It is not a big deal if your codes do not match the providers codes. It is a huge deal if your codes on the claim do not match the narrative in the note.
 
mitchellde said:
You would code based on the narrative note. It is not a big deal if your codes do not match the providers codes. It is a huge deal if your codes on the claim do not match the narrative in the note.
Click to expand...

Debra, what about those situations where the providers use the chosen ICD code as their ASSESSMENT, and really do not provide any other type of narrative, other than maybe " Continue current meds.." For example:


" Assessment:
1. Bilateral post-traumatic osteoarthritis of knee - M17.2 (Primary)

Plan:
1. Bilateral post-traumatic osteoarthritis of knee
Notes: Recent Xray showed severe osteoarthritis of the right knee."

No other documentation to support that the arthritis is "post-traumatic" So, how do I know that this is the true diagnosis vs an incorrectly chosen numerical code? As a coder, I have no documentation to either support or disclaim the Dx code chosen. Does this make sense? I know what I am trying to say, but not sure if I am communicating it properly....
 
If you look at coding clinic 2012 1st quarter it states that the provider is required to render the diagnosis in his own words and cannot use the numeric code as a substitute. In the body of the note does it address the condition at all? The body of the note is where I get all of my codes, I do not look at the assessment listing. So it should be addressed that this is post traumatic and what injury caused it. You do need to code the injury code also with a 7th character S
 
mitchellde said:
If you look at coding clinic 2012 1st quarter it states that the provider is required to render the diagnosis in his own words and cannot use the numeric code as a substitute. In the body of the note does it address the condition at all? The body of the note is where I get all of my codes, I do not look at the assessment listing. So it should be addressed that this is post traumatic and what injury caused it. You do need to code the injury code also with a 7th character S
Click to expand...

Nope! That is what is so frustrating. Came across 2 this week that were coded DM due to underlying condition, but no documentation, anywhere, as to what that underlying condition might be. Sent a query on that one. This is a new practice for me, started last month, so looks like provider documentation training will be in order. Thanks, Debra, I always value your opinion, not that I am a stalker!
 
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