Wiki Screening mammo

[hergett]

I was wondering can anyone tell me if there is no documentation for a screening mammo and you cant look into the persons other visits if they had hx breast cancer or absent breast because of our guidelines, would you wait for the documentation to be complete or would you code it as is a screening.
thanks
T

 

[mitchellde]

You must have the documentation that specifies the reason for the study or it cannot be coded. You cannot assume.

 

[hergett]

THANK YOU
i thougth the same and my work has been telling me to use v7612 without documentation and i refused to do so , i told my boss and also my lead coder that i am going bye the coding guidelines .
thank you for youre input

 

[hergett]

if anyone has any comments on this please post them i want to be sure and print this out and bring it into my boss and lead coder to show them, so i am not walking in blind and i have evidence on why i wont do them till the documentation comes in .
thanks again

 

[mitchellde]

See if this helps, it is from the first page of the Official ICD-9 coding guidelines:
A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

Just remember entire record for a physician claim is that day as you cannot go back in time.

 

[hergett]

Thank you so much its greatly appreciated
herget