Physician Practice

Q&A: You’ve got questions! We’ve got answers!

Physician Practice Insider, June 14, 2016

Submit your questions to Associate Editor Nicole Votta at and we will work with our experts to provide you with the information you need.

Q: Our providers are reluctant to document a correlation between symptoms and a detailed diagnosis. Do you have any good ways to get them to do this? For example, our providers document "diabetes" but they often don't include additional details that should be there (e.g., gestational diabetes or Type 2 diabetes mellitus in pregnancy).

A: The best solution is to query the physician in order to get those details. Ask the physician to document the specificity and make sure the query is through paper documentation or email so you have a history of how and when you queried for legal purposes.

Then, meet with the provider face to face. That will give you the opportunity to educate him or her as to why these details are necessary for coding and compliance. When you actually talk to the physician and show him or her why it’s important to have this information, the physician should be more likely to listen.
This process also ensures that if facing an audit from CMS or other payers, you have the documentation to prove you put forth due diligence in getting the information and reporting the condition correctly.

Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, and ICD-10-CM/PCS trainer, answered this question for Medicare Compliance Watch. She is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 20 years of experience.

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