Wiki New coder / Question about documentation

[Ccgerson]

I'm new to coding, just became CPC-A certified. My first question is related to ICD 10. When reading a medical record, if physician doesn't specify episode of care , but it's apparent in context of record what the episode of care is, can I code based on that? Or does physician need to document "initial, subsequent , sequelae".
Also, if documentation of the diagnosis is missing an element, however that information can be found elsewhere in the medical record , is it appropriate to code? For example , physician documents diagnosis as : sleep apnea. You see in history that patient has history of obstructive sleep anea. Can I code OSA?
Another example, physician documents diagnosis as "obesity ". You see in the medical record that patient has a BMI that places them in cAtegory of "morbid obesity ". Can I document morbid obesity? Or does physician need to modify his documentation ?
Thank you

 

[mitchellde]

The episode of care comes from the status of the injury and can be apparent from the documentation. Sequela must be documented as due to or caused by however so that you know the condition is sequela of the injury. You cannot obtain documentation from previous chart notes, it must be documented on the current chart note to be coded. You cannot interpret a diagnosis given other data such as a BMI, the provider must be the one to state whether it is overweight, obese, or morbidly obese.

 

[Ccgerson]

Great , thank you .

 

[Anita Johnson]

Previous chart notes when coding surgery

The episode of care comes from the status of the injury and can be apparent from the documentation. Sequela must be documented as due to or caused by however so that you know the condition is sequela of the injury. You cannot obtain documentation from previous chart notes, it must be documented on the current chart note to be coded. You cannot interpret a diagnosis given other data such as a BMI, the provider must be the one to state whether it is overweight, obese, or morbidly obese.

Hi Debra, If a provider links with date and signature, the H&P that was done when the decision was made for surgery and it is less than 30 days old, can you use it for additional diagnosis coding when the operative note does not include chronic conditions or comorbidities in the "Indications" section of the op note?

Thank you, I respect your advice.

Anita