Results 1 to 2 of 2

Missing documentation for external cause injury codes

  1. #1
    Location
    Savannah, GA
    Posts
    32
    Default Missing documentation for external cause injury codes
    New Call-to-action
    Patient comes in for a hospital f/u diagnosed with a concussion. There is no documentation in the visit note as to how it happened but it is very clear in the hospital notes. I have always been taught that a note must stand alone for coding so I queried my provider and asked her to please review as external causes were not documented. She does not feel she has to document this. Does anyone have any documentation they can share regarding this or am I incorrect to query my physicians when this happens?

  2. #2
    Default
    Per the ICD-10 official guidelines, external cause codes are not required - unless your state or payer mandates them, reporting is voluntary. In my previous practice, I would not query the provider or otherwise go looking for this information if it was missing from the documentation. I never encountered any issues with denials or rejects for not having these codes on the claim. Usually if the payer needs specific information about an accident, they'll request it in writing rather than require it in the coding.
    Thomas Field, CPC, CEMC

Similar Threads

  1. External cause for a car accident w/o injury
    By chasgiv4 in forum Diagnosis Coding
    Replies: 2
    Last Post: 01-31-2017, 12:54 PM
  2. Are there any codes missing?
    By MrsAllen07 in forum Diagnosis Coding
    Replies: 4
    Last Post: 08-13-2014, 04:19 PM
  3. Missing documentation
    By alk@APS in forum Auditing General Discussion
    Replies: 1
    Last Post: 01-13-2012, 09:49 AM
  4. Missing CPT codes
    By Dabzzy in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-06-2009, 03:48 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.