Results 1 to 4 of 4

Silly Question

  1. Question Silly Question
    Medical Coding Books

    I know this is probably a silly question, we have a Doctor that is performing cataract surgery, on his op note the only diagnosis he gives is just "Cataract"
    but in his H&P he actually specifies the type of cataract "Nuclear Sclerotic"
    For reporting purposes I believe the only Dx I can use is the one on the op note the unspecified cataract 366.9. I would love to hear some imput on this one as I queried the Doctor and asked that he specify the type of cataract on his op note, and he just said that it was listed on the H&P.

    Thanks in advance for any reponses.

  2. #2
    Not a silly question...I get confuse with this too...I guess is 'ok' to use the Nuclear Scerotic DX if it is documented on the H&P, but honestly, if it is not documented on the Ope Note and feel more comfortable using the 366.9...I think we need to instruct our doc's to be more specific on the Ope Notes...only my opinion

  3. #3
    Yes you can use the diagnosis from the H and P.!!!! We can use the entire medical record to select our code for what was done and why it was done. However the doc should be more specific in his op notes.

  4. Smile
    Thanks so much for the responses, I really appreciate it

Similar Threads

  1. Silly Question
    By alysn1drlnd in forum Employment General Discussion
    Replies: 2
    Last Post: 04-05-2013, 11:36 AM
  2. silly question V65.49
    By kumeena in forum Diagnosis Coding
    Replies: 2
    Last Post: 12-08-2011, 12:06 PM
  3. Silly question but need answer
    By codedog in forum EMR/EHR Systems
    Replies: 6
    Last Post: 12-01-2010, 11:55 AM
  4. Silly Question
    By DLT in forum Employment General Discussion
    Replies: 0
    Last Post: 09-24-2009, 12:50 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?


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.