Tip of the week: Check the anesthesiology note for missed CCs/additional diagnoses
HIM Connection, November 13, 2007
Want to receive articles like this one in your inbox? Subscribe to HIM Connection!
Don't overlook the anesthesiology note when reviewing a medical record. A physician in the anesthesiology department is more likely than a subspecialist to document that a patient has chronic obstructive pulmonary disorder, for example. "They [anesthesiolgists] have to give a complete body assessment in order to appropriately give anesthesia," says DeAnne Bloomquist, RHIT, CCS, chief consultant of Mid-Continent Coding, Inc., in Overland Park, KS.
A coder may code from another physician's documentation as long as the attending physician does not disagree with it, Bloomquist says. "If there's something ambiguous, the attending always has the final word," she says. Coding Clinic, 1st quarter 2004, pp. 18-19, confirms this guideline.
Just don't go overboard when interpreting this guideline, Bloomquist warns. If the only documentation for a CC is a radiology report, with no treatment of the condition, you cannot code it. "You must get a physician to document it, otherwise it falls into the category of 'incidental finding,' which should not be coded," Bloomquist says.
This tip was adapted from the November 1, 2007 issue of CDI Strategies. For more information, click here.
Want to receive articles like this one in your inbox? Subscribe to HIM Connection!
Related Products
Most Popular
- Articles
-
- Q/A: Volume requirement for reporting hydration services
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Catch up on what's new with injections and infusions
- Topic: CMS, OESS post new security compliance review information, checklist
- What does case-mix index mean to you?
- Capturing all necessary codes for IUD insertion and removal can be challenging
- QA:Coding multiple initial infusions
- News and briefs: Oklahoma Osteopathic Association against residency bill change
- HIPAA Q&A: Level of encryption needed for email
- OB services: Coding inside and outside of the package
- E-mailed
-
- Q/A: Volume requirement for reporting hydration services
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Catch up on what's new with injections and infusions
- New conflicts of interest create new challenges
- Q/A. One injection code or two?
- What does case-mix index mean to you?
- Q&A tackles coding questions about injections and infusions
- Joint Commission Center announces handoff communication solutions
- Inside best practice: Reduce patient falls with a stoplight
- Identify modifiable risk factors to prevent patient falls
- Searched