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Wiki Physician Documentation

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sspeer

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White Sulphur Springs, WV
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I have had a problem with a physician for years. His documentation is poor and even when there is a diagnosis, he isn't really specific when he chooses his diagnosis. It's usually unspecified. I don't know why I have so many issues with him and it is definitely worse now with ICD 10. I have my AAS in medical assisting so I know that I tend to go above coding only and review his documentation on the medical assisting side as well.
Since we are using an EMR and the E/m is populated at the end of a visit, I spend most of my time on diagnosis, cpt, modifier and chart reveiws.
I have a hard time when the doc doesn't code symptoms but codes a medical diagnosis when there is no testing to prove the diagnosis. Ie, appendicitis, fracture. I will typically hold the claim for results before coding and billing. If there diagnosis isn't confirmed I will code symptoms. I don't want any incorrect medical history going to someone's insurance company and creating problems for them in the future. Another issue, when I code a diagnosis to the highest specificity, it affects the practice management / billing side of the EMR only. What happens if/when we are audited and the coding doesn't match exactly to what the physician coded?
Every day I code, I create an excel spreadsheet and list each patient that is missing documentation for a diagnosis given, note to doc if I see a complaint that doesn't appear to be addressed in visit (although it may have), and also request infomation on a missing diagnosis for a medication prescribed. This happens with about 75% of charts.
Is this what others do? Help, it drives me crazy.
 
Coding other than diagnosis.

I am very sorry that you are having such a difficult time. Hopes things improve with your wise input to your physicians. In general, I understand that it is recommended to put symptoms instead of diagnosis if they are not confirmed, but remember that they are many clinical scenarios in which you may name a condition without having ant test done. Asthma (instead of dyspnea) fracture (instead of trauma an bone deformity) pneumonia ( dont need an xray necessarilly) and even appendicitis maybe diagnosed clinically if presented with clinical finding consistent with the condition. I am a provider learning coding, but even more, getting to know icd-10. I certainly can be poof wrong :-( hope this help!
 
I appreciate your response. I understand the conditions ie Asthma, pneumonia etc. but I question the fracture because a fracture diagnosis can trigger fracture care charges.
I guess my whole issue is that mostly the lack of supporting documentation. How often would you diagnose someone with Pneumonia or sinusitis with a normal exam?
 
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