Results 1 to 8 of 8

Thought this was an easy question...

  1. #1
    Location
    Ellenville, New York
    Posts
    1,176
    Default Thought this was an easy question...
    Medical Coding Books
    I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider. Sounded easy - first page of the Official Coding Guidelines, right? Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough. Any other ideas?

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  2. #2
    Default I can only give you a place to tell THEM to start looking.
    Your not the lawyer and you shouldn't have to be.
    If you look at the first page in ICD-9 under Official ICD-9-CM Guidelines for Coding and Reporting, states that "adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPPA). I believe that if they go through the entire document they will find the information they are looking for. Considering the length and the technical jargon, I personally would not even attempt to research it beyond that, due to the fact law is "outside of my scope of practice".
    I only word it this way, because that is how I would present it to them. Of course if anyone has something better, by all means please speak up, (I'd love to have a better answer)
    Last edited by nrichard; 11-16-2011 at 03:07 PM.
    CPC, COSC

  3. #3
    Location
    Hartford, CT
    Posts
    723
    Default
    Print out the CMS E & M Services Guide. The top of page four (also found in most insurance companies Medical Records Standards) states "The documentation of each patient encounter should include: 1) The reason for the encounter and relevant history, physical examination finding and prior diagnostic test results; 2) Assessment, clinical impressions or diagnosis; 3) Medical plan of care and; 4) Date and legible identity of the observer."
    Further down on the page there is a paragragh which states" When billing for a patient's visit, select codes that best represent the services furnishedj during the visit. A billing specialist of alternate source may review the provider's documented services before the claim is submitted to a payer. These reviews may assit with selecting codes that best reflect the provider's furnished services. However, it is the provider's responsibility to ensure that the submitte claim accurately relcts the services provided."
    The Guide goes on the say on page 5 that the two common sets of codes that are currently used for billing are: CPT and ICD.
    Page 6 also lists the providers who can furnish E/M services. Since the encounter must be documented by the person who provided the service, this may give them the answer they are looking for.

  4. #4
    Default
    Quote Originally Posted by MnTwins29 View Post
    I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider. Sounded easy - first page of the Official Coding Guidelines, right? Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough. Any other ideas?
    E/M Documentation guidelines sort of say it (Under MDM):
    "The number of possible diagnoses and/or the number of management options that must
    be considered is based on the number and types of problems addressed during the
    encounter, the complexity of establishing a diagnosis and the management decisions
    that are made by the physician
    .

    Generally, decision making with respect to a diagnosed problem is easier than that for
    an identified but undiagnosed problem. The number and type of diagnostic tests
    employed may be an indicator of the number of possible diagnoses. Problems which
    are improving or resolving are less complex than those which are worsening or failing to
    change as expected. The need to seek advice from others is another indicator of
    complexity of diagnostic or management problems.

    DG: For each encounter, an assessment, clinical impression, or diagnosis should
    be documented. It may be explicitly stated or implied in documented decisions
    regarding management plans and/or further evaluation.

    For a presenting problem with an established diagnosis the record should
    reflect whether the problem is: a) improved, well controlled, resolving or
    resolved; or, b) inadequately controlled, worsening, or failing to change as
    expected.

    For a presenting problem without an established diagnosis, the assessment
    or clinical impression may be stated in the form of a differential diagnoses or
    as "possible,” "probable,” or "rule out” (R/O) diagnoses."

    The 'general principles' say that the diagnosis should be clearly indicated, along with the legible identity of the observer, but it doesn't say that it MUST be a physician. I also think that it probably falls somewhere under 'scope of practice' criteria, but I'm not sure...

  5. #5
    Red face
    Quote Originally Posted by MnTwins29 View Post
    I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider. Sounded easy - first page of the Official Coding Guidelines, right? Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough. Any other ideas?
    I thought you were asking about something more along legal guidelines to present to them.
    CPC, COSC

  6. #6

  7. #7
    Location
    Ellenville, New York
    Posts
    1,176
    Default Thanks!
    Quote Originally Posted by nrichard View Post
    I thought you were asking about something more along legal guidelines to present to them.
    Yes, that is the direction I was going with it - espcially when the follow-up question came when the Official Guidelines were not clear enough for the person who asked me. However, I am going to gather all of your suggestions and present them. I didn't think of the E/M guidelines since this issue didn't involve E/M coding, but when I re-read them after reading these responses, I think that will certainly help.

    Thanks to all who responded.

    Lance

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  8. #8
    Location
    Connecticut
    Posts
    26
    Default
    Quote Originally Posted by MnTwins29 View Post
    I was asked by our legal department where it is stated that the documentaion for a diagnosis that is coded must be documeneted by a physician or legally responsible provider. Sounded easy - first page of the Official Coding Guidelines, right? Well, because it doesn't explicitly say "physician", I am being asked to find another source....and that is proving tough. Any other ideas?
    The introduction to ICD-9-CM Offical Guidelines for Coding and Reporting states "The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient's diagnosis." This statement is in the fourth paragraph.

    The ICD-9 Guidelines are mandated by HIPAA and must be adheared to whenever transmitting healthcare data from one party to another party for payment. This is stated in HIPAA, not in the guidelines.

    The party responsible for issuing payment for services dictates who is a "quilified health care practitioner" and this differs by payor. Such as one payor will remit payment for a service provided by a nurse practioner, where another will not remit payment unless the documentation is signed by a physician. Some payors will remit payment to a Licenced Social Worker, a Massage Therapist, a Chiropractor, while others will only remit to an MD.

Similar Threads

  1. Probably an easy question for most of you....
    By sheardmd in forum Emergency Department
    Replies: 0
    Last Post: 10-06-2014, 09:30 AM
  2. probably an easy Preventive visit question?
    By ollielooya in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 09-10-2012, 09:16 AM
  3. Easy Question
    By solocoder in forum Podiatry
    Replies: 1
    Last Post: 09-01-2011, 03:52 PM
  4. I'm sure this is an easy question..
    By happytobecoding in forum Auditing General Discussion
    Replies: 2
    Last Post: 01-19-2010, 09:08 AM
  5. Need help with an easy question
    By annarn in forum Diagnosis Coding
    Replies: 3
    Last Post: 08-22-2009, 10:52 AM

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.