Wiki N18.31, 32 issue

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mamurph34

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I am having an issue with a 3rd party vendor who is stating that if a provider codes N18.31 or N18.32 with MEAT, but uses the term CKD3 only in the discussion of care that the code needs to be N18.30. Thoughts?
 
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I agree with the vendor on this. If the provider is not specifically stating Stage 3a or 3b, I would not assign the more specific code. When we know our providers well and how they document, we know what they mean but if they don't specifically say it, we can't code it. I may *know* a patient is anemic based on their lab results but I can't diagnose the patient so if the provider doesn't say the patient is anemic, I don't get to assign that ICD-10 code.

Others may have a different opinion but there's my $.02 on the matter.
 
I think my issue is that the provider has to first select the code, then that brings it into the EHR. At that point they add their documentation to show the issue was addressed, and it appears directly after the code in the note. Rarely do they restate the code-it looks like this " Impression: Chronic Kidney disease stage 3 (moderate) N18.31-Plan: continue medications as directed, schedule appointment with nephrologist Dr. X, labs to be done today"

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mamurph34 said:
I think my issue is that the provider has to first select the code, then that brings it into the EHR. At that point they add their documentation to show the issue was addressed, and it appears directly after the code in the note. Rarely do they restate the code-it looks like this " Impression: Chronic Kidney disease stage 3 (moderate) N18.31-Plan: continue medications as directed, schedule appointment with nephrologist Dr. X, labs to be done today"

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IMO, the code has to match the verbiage in the documentation. Regardless of whatever code the provider self-selects for the encounter.

If the provider doesn't spell out stage 3a or 3b in the documentation and just says "stage 3" then I code N18.30. They should be using the verbiage for 3a or 3b when applicable in order to code the codes.

If this turns into an ongoing issue, it could be a good opportunity for provider education.
 
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