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coding to highest degree

  1. #1
    Default coding to highest degree
    Medical Coding Books
    My supervisor has informed us that we must code to the highest degree. She does not want any unspecified codes used. Our physicians that are seeing hospital based patients are so general, they do not give much detail to the diagnosis code. Many times there is no other specific information to use a more specific diagnosis code. What am I to do if documentation only meets the unspecified code and nothing more specific?

    Thank You
    Monica

  2. #2
    Default Unspecidfied codes
    You can query the physician to get more information. Also, remember if it is an inpatient chart you can code symptoms. Hope this helps!!

    Amanda Yarber,CPC

    ****If your company does not already have a process for querying physicians let me know and I can get you some material on that.

  3. #3
    Thumbs up
    Quote Originally Posted by busydawnis View Post
    My supervisor has informed us that we must code to the highest degree. She does not want any unspecified codes used. Our physicians that are seeing hospital based patients are so general, they do not give much detail to the diagnosis code. Many times there is no other specific information to use a more specific diagnosis code. What am I to do if documentation only meets the unspecified code and nothing more specific?

    Thank You

    Remember the Golden Rule. It might save you in the long run.

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Coding for physician or facility?
    Are you coding for the physician or for the facility/hospital?

    If your supervisor does not want to see "unspecified" codes, then some education of the physicians is in order. You can only code what they have documented.

    F Tessa Bartels, CPC, CEMC

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