Diagnosis Coding: Here’s How To Decode Your Physician’s Notes

Posted on 16. Jun, 2010 by Editor.

If the doctor does not circle a diagnosis, it may be up to you to find one.

Don’t let an incomplete superbill damage your chances of submitting an accurate claim. If the doctor in your office fails to indicate the ICD-9 code for the condition that he treated, you should read through his documentation to find which diagnoses you should report.

Open the Notes When You Have to — and Even When You Don’t

Suppose your physician hands you a superbill with the procedures circled and the diagnosis left blank.

You could ask the physician which diagnosis to report, or you could examine the documentation yourself. If your office has a policy that includes “coding by abstraction” by certified/qualified coders, then

Continue Reading

Endoscopy Documentation Checklist for Physicians

Posted on 05. Jul, 2009 by .

Do you feel like you never have enough information in your gastroenterologists’ endoscopy reports to code correctly? Here’s help. Give them this handy little documentation checklist that they can refer to when they dictate endoscopy procedures:

If the patient had multiple polyps or lesions, describe location and treatment method for each one. “Multiple polypectomies” does not give your coder enough information.

Provide both pre-op and post-op diagnoses. If there were no findings, use the pre-op diagnosis twice.

Document a specific anemia diagnosis, if appropriate. Most Medicare payers won’t accept 285.9 (Anemia, unspecified) to support colonoscopy or EGD.

If the patient had a screening colonoscopy due to family history of colorectal cancer, document which family member or members. Must be sibling, parent, or child to qualify.

If you used a templated electronic health record, make sure descriptions actually match what was performed. If there were differences, add notes of explanation to prevent coding errors.

ON DEMAND: Stellar strategies for coding upper GI endoscopic procedures, from Jan Rasmussen.

© Gastroenterology Coding Alert. Get 2 FREE sample issues.

Continue Reading