Wiki Pulling Diagnosis/Sign/Symptom from EHR

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1formissy

1formissy

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Hello Fellow Auditors,
By day, I am a coder, by night, an Auditor. So, I am always going back and forth with this issue and thought I would reach out to my colleagues for their insight.
Our physicians do diagnostic imaging interpretations for the hospital. When coding those services, many times I come across documentation where there is no sign/symptom/definitive diagnosis. The indication will say, "Trauma."
So, our coders are forced to look in the EMR to find a definitive diagnosis/sign/symptom.
As an Auditor, this does not sit well with me, because the documentation MUST support the service(s) reported. Therefore, if a claim comes across as S09.8XXA (Head injury), but the documentation says Trauma and nothing else, (conclusion in the record will say something to the effect of "No abnormal findings), I do not find that compliant.
I searched online for some indication from Medicare regarding this, and found nothing.

Comments?
 
I agree. When you are coding for one physician ( the one interpreting the result), you cannot use information from the other physicians record that was not conveyed on the order. If I were coding that result, with the indication of trauma, and a result of no finding, I would use the Z04.3 code.
 
The link below is information that was included by CMS in the claims processing manual in chapter 23 when ICD-9 was in effect, and gave the guidance that "when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician."

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/ab01144.pdf

I had always found this a useful reference for guidance in these situations and others where there were discrepancies between an order and the information in the patient's record. Unfortunately though, this section of the manual was removed in September 2014 when ICD-10 went into effect and was not replaced with updated guidance, and I've never been able to determine if this was removed intentionally or what the current expectations of CMS are under ICD-10.
 
mitchellde said:
I agree. When you are coding for one physician ( the one interpreting the result), you cannot use information from the other physicians record that was not conveyed on the order. If I were coding that result, with the indication of trauma, and a result of no finding, I would use the Z04.3 code.
Click to expand...


Thank you Debra
 
Thank you Thomas. I find that interesting that nothing has been updated since ICD-10. (Or so it may seem). Appreciate your assistance in this as I pursue this somewhat frustrating topic.
It remains difficult to educate physicians on what is expected in terms of coding and documentation, where there seems to be so many grey areas. Although most of the physicians I interact with are eagerly to do the right thing, there are other's with whom do not agree until they see something in writing from the source.
 
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