Wiki Pelvic floor dysfunction ICD10 ?

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ARON-A

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Hi All
I am just leading code for pelvic floor dysfunction in ICD10 but couldn't able to get a proper code any suggestions ?
 
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There is no documentation of Neurogenic or Neuromuscular in my record in this case what i can do ? can you please advice
 
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I would go with N319-Neuromuscular dysfunction of bladder, unspecified. Also code additional if documented, identifying urinary incontinence N393-N394X series. However, the best thing to do is query provider for clarification concerning whether condition is Neurogenic, Neuromuscular, or both. Part of ICD-10 CM is the specificity of the diagnosis. And that means we need to prompt the providers into documenting conditions more completely in the medical record. This can reduce unpaid claims because you can't defend "not documented"
 
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Thank you so much, I found your answer is the most relevant among all my network searches and queries i will be informing providers for documenting conditions more completely in the medical record which will be useful in coding sorry for the delayed reply
 
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Aron,

You are most welcome.
Most of our coding challenges is informing providers of documentation requirements for ICD-10-CM. We can no longer let providers document in such a way that leads to inability to fully report the encounter for reimbursement purposes. Most providers know this. However, sometimes they think what they document is sufficient when certain diseases and processes require a specific documented path to ensure proper reimbursement.

Empowering providers with knowledge and awareness on what needs to be documented reduces what I call "Coding Fallout" When you have another situation where you can't quite secure a code, then as a suggestion, have a non-leading query designed for provider to help you assign the most accurate code while maintaining the integrity of medical record documentation. This builds respect from Providers.

Happy Coding!
 
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