kdlberg
Guru
This is a trend we've spotted with a client and we need a better answer than "because it's like this other rule."
Patient had low level of vitamin D on previous visit, the provider added E55.9 and told the patient to start taking supplements. The most recent visit lists E55.9 in the A&P with "lab 10/14 WNL, continue to monitor."
One of us wants to keep E55.9. Their justification is the same as coding for an arrhythmia in the presence of a pacemaker: if the patient stopped taking the medication, the problem would return. In addition, the provider is saying the patient has the condition. The other wants to take it off, because the condition has resolved and it may not return. Copy/paste is a major problem with this office so it's also possible the provider just copied/pasted the diagnosis list from a prior visit.
I've looked for a definitive answer and can't seem to find one. Ultimately, we want to educate the providers on what they should do--besides stop cloning, which I've already said about 42 times and they keep doing it. (We're a business associate, so all we can do is advise.) Can someone point the way? Thanks!!
Patient had low level of vitamin D on previous visit, the provider added E55.9 and told the patient to start taking supplements. The most recent visit lists E55.9 in the A&P with "lab 10/14 WNL, continue to monitor."
One of us wants to keep E55.9. Their justification is the same as coding for an arrhythmia in the presence of a pacemaker: if the patient stopped taking the medication, the problem would return. In addition, the provider is saying the patient has the condition. The other wants to take it off, because the condition has resolved and it may not return. Copy/paste is a major problem with this office so it's also possible the provider just copied/pasted the diagnosis list from a prior visit.
I've looked for a definitive answer and can't seem to find one. Ultimately, we want to educate the providers on what they should do--besides stop cloning, which I've already said about 42 times and they keep doing it. (We're a business associate, so all we can do is advise.) Can someone point the way? Thanks!!