Where in the chart can coding info come from for private practice

kimberagame

Contributor
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20
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CORVALLIS, OR
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Hello all,

With the reduction in provider documentation burden that has been implemented in recent years, I'm seeing some of our providers becoming much more vague on details in their office notes. Not documenting laterality has been a big problem. They say the details were documented previously in the chart, and they don't need to keep repeating them each time with these new rules. I understand and agree that this is the case for them, however, I've yet to see anything that has allowed coders in private practice settings to draw information from anywhere other than the note they are currently coding. I understand that hospital coders can draw info from anywhere in a patient's chart, but my schooling (about 6 years ago now) was for the clinical side, and we were taught everything had to come from the office visit note being coded. The only exception was if a previous note was referenced by date, we are allowed to draw info from that note as well. I learned this, and all the coders at the job I subsequently got also held this as law. My question for you is, has this changed? Or was this incorrect to start with? Any time I look into where coders can get info, sources say it can come from anywhere in the chart. But I'm concerned the source is talking about hospital coders, since I know that's the case for them. Can coders on the clinical side also take our info from anywhere in the note? Thanks for your help!
 

TThivierge

Guru
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Lithonia, GA
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Hi Kim,
The treating provider should report notations clearly & correctly each visit on the day of treatment. This means by putting down if right or left leg, ear, eye Etc. If auditor looked at this record, they may skimming thru the record but records should be detailed and complete . If it is sent to an insurance company; they will not be happy thus you may have payback. The code claim for payment must match supported documentation by the provider. No one knows when insurance company may want scanned copy of the medical record, so documentation should be complete correctly EACH time. Documentation should be able to stand on its own. Doctors must think in ink to the coder to get right funding outcome. Some doctors feel if inpatient coding can be scanned and eyeballed to ensure data in other part of progress or nursing notes during time period pt. inhouse. .The inpatient coder can do this HOWEVER the physician needs to document laterality of limbs, organs, Etc. Transmitting claims with unspecified dx. code related to laterality organ or extremities ; reduced pay or may get it denied. Outpatient setting this can happen if provider not understand the importance of documentation=coding=revenue.
I hope this data helps you
Lady T ;)
 

TThivierge

Guru
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Lithonia, GA
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Hi Kim
Me again...I'd take info on outpatient setting from the current HPI stated from the provider for treatment on the date patient seen. Does the past med history help you if ongoing problem. The past medical history can be used if related to the current problem. As example provider state patient has ongoing left leg pain from crushing injury like 2 years ago or he has DVT of the left leg. But going back in previous 3 or 4 past old outpatient dates of treatment .,nope that is wrong. sometimes you' ll have current xray reports done same day or day later tell you which leg or arm related to illness. But the coding rule states doc be complete and list all data in treating record for the outpt. setting. It is listed in the ICD10 manual see section on unspecified section only use that when no info provided or provider does not know. Also the Chp. 13 Ds. of the Muscluloskeletal in ICD10 tells you to use laterality codes. I hope the providers are using laterality for the organs such as adrenal, kidneys, testicles, fallopian tubes, lungs, thyroid, pressure ulcers, too if not they are not being specific.. Also if treating certain sections of the colon it has differ sections should be familiar with too. Ahh they need to get with the common coding standards or show them the denials or less fund. Again hope this data helps you.
Lady T
 

sinman0531

Networker
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Tampa, FL
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Yes, I am having this problem as well, especially when it comes to the 99214. They think if they throw 15 diagnosis codes on a visit note with zero information, it should be proof enough based on volume alone.

The way I look at it, each visit note/finding needs to tell a complete story. It doesn't have to be an in-depth epic of a story, but it should provide context/relevant history and a complete picture. I work at a dermatologist, so the minimum I'd be looking for is something like "f/u wound check post excision 10/01. Site is erythematous and warm, but no oozing. Advised patient to wash gently with warm soap and water once per day. No hydrogen peroxide. Advised to keep clean and dry, f/u in 7-10 days"

and then anything after that to have something to the effect of " wound check post excision 10/01. f/u on 10/15 showed mild erythema...."

I would not expect an insurance company or auditor to pull relevant information from the CC/HPI area of our chart note since a lot of times what the patient books the visit for is not what they end up talking about in the office. It also violates minimum necessary standards to have to reference (and therefore send) multiple visit notes to justify a single DOS. Thankfully my providers (I code for 12) haven't been too combative because I will send an EMN back.
 
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