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Unspecified codes and medical records

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dirtymartini77

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3
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Portland, OR
Hello. Relatively new to the coding world and experiencing some confusion on our team regarding the use of unspecified codes that have previously been used in the patient's past medical record/history as a specified version. (Example: Unspecified A-Fib for this encounter, but the pt has numerous, previous encounters: office visits, procedures, etc. with a Chronic A-Fib code)

Are we allowed to change the existing unspecified code to the specified version if there is medical record documentation?

I am also stating for the purpose of this particular example, I do also understand that the documentation must reflect that (chronic) condition. In my specialty, (cardiology) the providers tend to drop the encounter with the unspecified codes as a default, just to get them into the queue and from there we are to specify. I am trying to clarify that I CAN or CANNOT use a pt's past medical record to extract a specified code and change it.

Thanks so much in advance!!!! :)
 
You can only use the documentation for the current stay or visit to code that encounter. If the current documentation is coded as unspecified yet the provider documents specificity then yes you can change the code. However if you have to go to previous visits/encounters to obtain that specificity then no you cannot do that.
 
Coming into this conversation late but we just had this same issue come up in a billing meeting yesterday. Do you happen to know a resource that I can provide my Director that will support changing the unspecified dx according to the supporting documentation on the current encounter rather than having to query the physician?

Any help is greatly appreciated!
 
From my experience, whether or not a coder or biller may change a code from the physician (as long as it's in the documentation) is strictly a policy of the organization you work for. Obviously, you cannot change a code that is not documented. But oftentimes as the original poster stated, the physicians simply pick the first code that is close, regardless of whether it is 100% accurate. Small practices not owned by a larger system, it will depend on what the physician prefers, which is typically as little involvement as possible. Larger healthcare organizations will typically permit certified coders, but not billers, to change codes already in documentation without a query to the provider. It's easier for everyone involved, and facilitates submitting a claim faster.
 
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