verify Dr. diagnosis

LuckyLily

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Local Chapter Officer
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If I am to verify the coding of the doctor, does the doctor need to be very specific in the charting of documentation. For example, doctor gives diagnosis of
I50.41 (acute combined systolic (congestive) and diastolic (congestive) heart failure). But in Medical History only CHF is documented. Another example is
I83.813 (varicose veins of bilateral lower extremities with pain) In documentation does Dr. need to say all of the key pieces in documentation, usually all I get are varicose veins of lower extremities. Nothing about pain.

My problem is, I am to verify the codes the Dr. gives. However the codes given are more in depth that what the information is documented in the chart. I don't understand the concept of the doctor giving the codes then the coder verifying them.

Thanks for your help.
 

ancoleman22

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If I am to verify the coding of the doctor, does the doctor need to be very specific in the charting of documentation. For example, doctor gives diagnosis of
I50.41 (acute combined systolic (congestive) and diastolic (congestive) heart failure). But in Medical History only CHF is documented. Another example is
I83.813 (varicose veins of bilateral lower extremities with pain) In documentation does Dr. need to say all of the key pieces in documentation, usually all I get are varicose veins of lower extremities. Nothing about pain.

My problem is, I am to verify the codes the Dr. gives. However the codes given are more in depth that what the information is documented in the chart. I don't understand the concept of the doctor giving the codes then the coder verifying them.

Thanks for your help.

I personally would think that they need to specific in their documentation.

If I were to pick up the chart to review it and it was not specified in the documentation as acute combined systolic and diastolic heart failure, I would have no choice but to take it to just Heart failure, unspecified.

I feel like the documentation needs to match the coding. Otherwise, I would be wondering where you got the rest of the documentation to take it to acute combined heart failure.
 
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For example, doctor gives diagnosis of
I50.41 (acute combined systolic (congestive) and diastolic (congestive) heart failure). But in Medical History only CHF is documented.

Another example is
I83.813 (varicose veins of bilateral lower extremities with pain) In documentation does Dr. need to say all of the key pieces in documentation, usually all I get are varicose veins of lower extremities. Nothing about pain.

Are you billing for E/M encounters?

When you say "Medical History" for the CHF, do you mean that the provider listed the condition as "past medical history?" Is the visit to review/re-evaluate this condition?

For the varicose veins, is this a new or established problem? Is the condition the primary reason for the visit?

I only ask because sometimes documentation from office visits, for example, contain all necessary information, just spread all over the place....
 

LuckyLily

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Local Chapter Officer
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I am not determining the E/M level that is put on the claim. I am only looking at the diagnosis that the Dr. documented. This is for a clinic for patients who have wounds, ulcers, or long term skin conditions. I know how to determine what the patient is in the clinic for, it is all of the other diagnosis that the Dr. applies.

The CHF is listed in the "Medical History" and the doctor does not evaluate the condition, but thinks that it has importance on the wound that is being addressed due to healing ability.

The way that the program is set up is that there is a heading saying "Assessment" with the diagnosis codes that the doctor picks. There is no other documentation area where the doctor types in the diagnosis for the patient. Just the code and the code descriptor is used.

Patient does have varicose veins, and this does play a factor on the wounds, but the Dr. will list it with "pain" but doesn't document that there is pain with the varicose veins.
 
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