Question Which part of the documentation can Coders use to code from?

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I'm really sorry if this has been posted before but I couldn't find anything when I searched the forum (probably because I couldn't figure out how to phrase it correctly.)

Which part(s) of the documentation can coders pull dx codes from? Say, the provider only listed BMI or Obesity on the claim. We have to go back to the encounter notes to see what the provider wrote and pull a good diagnosis. I'm a new coder, but I was taught we could use anything the provider documented (HPI, ROS, Assessment, Plan) but there's another lady where I work who stated we cannot code from history. Not just the medical/surgical history but also the history of present illness.

Can someone please shed some light on this and if you have it, list a source or two where I can check this out myself? I've Googled this so many times and I searched AHIMA, AAPC but did not find what I was looking for. As I stated before, the fact that I didn't find anything is most likely due to not being able to search the correct combination of words or phrases.

Please help (and THANK YOU)!
 

Rajinder_Dhammi

Networker
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Hi Mary,

The advice given to you by that lady is partially correct. You cannot actually code from HPI or ROS for confirmed dx purposes, as the HPI briefs all the signs and symptoms (narrated by the patient to the doc) with which the patient presents.

The areas from where you can actually code from a medical document ( FOR CONFIRMED DX ONLY):

Assessment/Impression/Diagnoses:
-Code this/these at the first place (Caution: Please be highly vigilant if something is documented as differential diagnoses, never code it, as they are suspected dx).
Physical Examination: - Can be used for coding, as the doctors examine those different body areas themselves. For eg: A doctor examines skin and documents a linear laceration measuring 2 cm on right forearm, then it is a sure shot dx that can be billed.
Diagnostic Impression: - All these dx are confirmed by doctors after they have interpreted the x-rays, ultrasounds, CT scans, MRIs, etc.
Past Medical History/Past Surgical History/Medications: You can code from these areas too if required for chronic illnesses and status codes.

HPI and ROS - To be used only in case there is no confirmed dx.

If you have any other doubts/queries/issues, kindly don't hesitate and please feel free to contact me at rajinder_dhammi@yahoo.com

Would always be there to help you.



Thank you,
Rajinder Singh Dhammi, CPC
 
Last edited:

thomas7331

True Blue
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I would disagree with the above - there is no rule or guideline that the diagnosis cannot be taken from the HPI or any other section of the documentation - only that the diagnosis must be documented "by patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis)" as existing or affecting care at the time of the encounter. "Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider." In the event that it is necessary to code symptoms, these in fact often are documented by the provider in the HPI. (Refer the ICD-10-CM Official Guidelines for Coding and Reporting for this guidance and additional detail about the requirements for reporting diagnosis codes.)
 
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