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Wiki medicare auditing for payor

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eileenmaryhelen

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When coding charts for Medicare audits: If a pcp is coding cancer as current and the specialist is saying the patient is in remission can we change the pcp code to hx of cancer?
 
The code should be chosen that best reflects the provider's assessment of the patient as it is stated. It would not be appropriate to change one provider's code based on information from a different provider - providers do not always agree on a patient's diagnosis. But if you think the evidence shows that one provider may have simply selected an incorrect code, or there are inconsistencies in the information within a note, then it might be best to query that provider for clarification.
 
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