states diagnosis in assessment, then says possible in plan

Dfreddie

Networker
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Beach, North Dakota
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I come across this often. The provider will state in the assessment, for example, Actinic Keratosis. He freezes it and enters the 17000 procedure code. Then in the plan he says treated possible AK with liquid nitrogen. So, now that he's saying "possible" in the plan, even though it was diagnosed in assessment, doesn't that mean I have to change that dx and, in this case, the procedure code as well?
 

thomas7331

True Blue
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3,152
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This sounds like inconsistent information in the record and something that would normally require a query to the provider. If you're seeing this a lot, I'd speak to the provider about it. A possible diagnosis and a definitive diagnosis are different things and coded differently. The provider has the right to choose which one they feel is most correct, but they can't have it both ways.
 

Dfreddie

Networker
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Beach, North Dakota
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thank you. That's why it gets frustrating - documentation doesn't match for what they want to code/bill, and they don't understand why I have to change it if they can't/won't clarify. :rolleyes:
 
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