Health Information Management

Q&A: Code or query for clinical significance?

JustCoding News: Inpatient, March 28, 2012

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QUESTION: We are having a discussion about how to code when the studies section of the history and physical (H&P) indicates that the chest x-ray showed atelectasis or that an electrocardiogram showed right bundle branch block with anterior fascicular block. Some of us believe that it’s okay to code the diagnosis (i.e., atelectasis) if the provider states that the testing “showed” the diagnosis, whereas others believe we cannot code the diagnosis as it is a lab/testing result, and the provider could just be reading the results onto his or her H&P dictation.

I realize you cannot go to the testing result itself and code from it directly. However, I argue that it would be okay to code for it because the provider is using this information to make decisions about care, testing, and procedures, and he or she indicates the testing results in the H&P body. What are your thoughts?

ANSWER: Most of the time these kinds of findings are “incidental.” In other words, they may have no clinical significance. It’s important to investigate whether these “new” findings lead to additional interventions, medications, more workup, etc. If not, then they most likely do not meet criteria for coding or reporting.

Just because something is mentioned does not mean we should code it. If I review the record and don’t see a direct correlation between a documented diagnosis and orders for care, I query for the clinical significance of the diagnosis.

We are seeing more and more copying and pasting of diagnostic findings from diagnostic reports into physician notes with no further documentation of clinical significance, treatment plan, etc., so you must be very cautious about coding these, and consider querying the physician to either confirm or rule out.

Editor’s note: This question was answered by Lynne Spryszak, RN, CCDS, CPC, an independent HIM Consultant in Roselle, IL, and Sue Belley, M.Ed., RHIA, CPHQ, project manager at 3M HIS Consulting Services, in Atlanta, GA. This Q&A was published in the March 15 issue of CDI Strategies. E-mail questions to Managing Editor Doreen Bentley.

Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to Managing Editor Doreen Bentley, CPC-A, and we’ll do our best to get an answer for you.

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