Physician refusal to correct coding error in record-I found a coding

lsmft

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I found a coding error in my own medical record. Evidently the physician put 493.21 (chronic obstructive lung disease with status asthmaticus) in rather than 493.00 (extrinsic asthma). There is a huge difference in those two codes and I do not have the one that appears in the records!!
After nearly 20 phone calls the clinic now tells me that I have to have a pulmonary function test to prove the coding error wrong and convince the physician to correct the records. This is of course additional testing and I will have a copay for a test I don't need.

I am going in circles with a diagnosis that is very incorrect and I am getting nowhere with this issue. Is this a compliance issue? Where do I go from here? Help!!
 

mitchellde

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What code was put on you claim.. As long as the narrative states extrinsic asthma the code on the claim must match the narrative. So the question is not what code did the provider use but what was documented as the diagnosis. Then go from there.
 

lsmft

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Trying to get medical records

Thank you Debra. I am having difficulty obtaining copies of my records from this institution but I will make another call today. Thank you for the advice, this helps to know.
 

Annette

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Under HIPAA, you have the right to view your records, (if they are electronic you may have to go to their office to view on-line). You also have the legal right to request a change in your medical record, if the physician documented something you feel is incorrect. Note I stated "right to request", they can refuse, but you also have the right to contact the Office of Civil Rights and file a complaint, regardless of the outcome. As far as a compliance issue, HIPAA is the point. His choice in diagnosis codes, whether they be right or wrong, will not send the FBI to his door. However, you are right to be concerned. Extrinsic Asthma is usually associated with allergies, as you know. COPD can of course become life threatening. When diagnosis codes are reported on claims to payers, they can become part of a file held by the MIB. The MIB is a data center that supplies these diagnosis to life insurnace companies, when you are applying for coverage, so ultimately, you could be denied life insurance, for a wrong diagnosis on your record. You can contact the MIB yourself, and find what is on file for yourself. When people do this, they often find errors they weren't aware of, and yes, there are routes to correcting those as well. Best of luck.
 

LLovett

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Status asthmaticus is a medical emergency. Where you treated as such? Likely sent to the ED or admitted to the hospital?

My guess is the note will match the bill because it is probably on an EMR in which the provider completes the assessment portion by choosing a dx and code from a drop down list. Which then gets pulled over to the charge portion of the system.

If the provider won't correct the issue, call your insurance carrier and file a complaint. Let them do the investigation.

Good luck,

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 

mitchellde

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The provider cannot use the dx code with its descriptor as the documented dx. The provider is required to render the dx in his own words in the note. So using a drop down with codes and descriptions is not used as the dx is probably ok.
 

LLovett

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Debra do you have something from an official source in writing stating that drop down ICD boxes are not acceptable in medical record documentation?

I absolutely hate it and would appreciate an official source that could put an end to it. I would love to see this. Nearly every newer EMR I have worked with is set up this way. The providers don't even have an option to free text their own words for the diagnosis portion in many cases, just the plan piece is open. I work with providers on CIA's that have this set up and that was not an issue even mentioned by the government.

Thanks

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 

mitchellde

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Coding clinic 1st quarter 2012. This is not a free publication but you can purchase individual issues. I am not allowed by copyright to post the exact wording from the coding clinic.
 

LLovett

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That coding clinic is addressing use the code number instead of any verbiage. I don't think you can extrapolate that out to mean that EMRs that have diagnosis codes linked to the verbiage in their drop down boxes are not permissible to utilize. If so, several major EMRs are in serious violation of this.


Thanks

Laura, CPC, CPMA, CPC-I, CANPC, CEMC
 

CatchTheWind

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I would repeat Debra's question as to whether the error is in the verbiage of the medical note or only in the CPT code used. You have a HIPAA right to get either one of these corrected, but you should first know what it is you are requesting! (Regarding your difficulty in getting records from them, they have a HIPAA obligation to provide the records within 30 days of your written request. (They can have a 30 day extension if they notify you within the first 30 days that they will need it, but they only get one extension.)

To expand on Annette's answer, if the problem is with the actual record (not just the ICD-9 code), and you make a written request for an amendment of your medical record, they have 60 days (plus one 30 day extension if they have notified you in writing within the first 60 that they will need it) to either make the change (and send - at no charge - a copy of it to you and anyone else they had sent the original record to) or to send you a letter stating that the record is already accurate. (You have no obligation to prove to them whether or not the record is accurate; it is up to the provider to either stand by his record or admit that it was faulty. And the provider's obligation to comply with this HIPAA requirement is not dependent on your agreement to get additional tests!)

If the provider replies that the original record was accurate, he is not required to amend it. However: (a) You have the right to write a statement of disagreement, which he must include (along with your original request for amendment and his reply/replies) or an accurate summary of those, in any future releases of that medical or billing information. (b) If he insists that it is correct when you know that it is not - or if he fails to respond in the prescribed time-frame to your request for records or for the amendment - then you have the right to file a written complaint to the Office of Civil Rights for a violation of your HIPAA rights.

If the problem was only with the CPT code, although HIPAA would theoretically protect your right to get an amendment there, too, it may be simpler to go directly to your insurer and see if they will be willing to do the work for you. Once you have advised them that they submitted an incorrect code, I would hope that they would want to request records and/or take back the payment until the claim is corrected.
 
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