Below is a complete listing of all Ask the Expert articles that have appeared in JustCoding News.
August 14, 2011
QUESTION: Some of our physicians are uncomfortable making addendums to the discharge summary to include the pathological findings (e.g., malignancy). They feel it would be illegal to make an addendum to the discharge summary when the pathology report comes back after the patient is discharged. Instead, they dictate a Tumor Board Note that summarizes the patient's course of treatment and final pathological diagnosis. Our concern is that the Tumor Board Note is usually dated a few days after the patient is discharged.
When a condition meets reporting guidelines for the inpatient admission, is it appropriate to use documentation dated outside the inpatient admission for coding purposes? Are there specific laws or guidelines that prohibit coding from documentation dated outside the inpatient admission?
For example, a patient is discharged January 1 with a diagnosis of uterine mass. The pathology report comes back January 3 showing uterine cancer, and the physician documents a Tumor Board Note that states “uterine cancer” January 5. Can we assign a code for uterine cancer based on this Tumor Board Note?
August 9, 2011
QUESTION: We have a coding question regarding antibiotic infusion therapy. During the initial visit, the provider determines the patient will come in daily for IV antibiotic infusion therapy. The provider writes an order for the therapy, which a nurse in the outpatient clinic completes. The provider does not see the patient during the infusion.
Do we report an initial IV therapy code on each day this patient returns for treatment (the patient uses the same account number) in addition to CPT® code 96366 (IV infusion for therapy, prophylaxis, or diagnosis [specify substance or drug]; each additional hour) or should we report code 96366 without code 96365 (IV infusion for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to one hour) for subsequent days?
August 2, 2011
QUESTION: Auditors have denied some of our charts because the “diagnosis in the discharge summary is conflicting and should have been queried.” If the diagnosis is unspecified on the discharge summary and there is substantial documentation of specificity in the body of the chart (e.g., progress notes, consults, and history and physical), can we code the more specific diagnosis or should we query the physician because it is not specified on the discharge summary? For example, how should we proceed if the discharge summary indicates “acute congestive heart failure (CHF)” but the progress notes and consults document “acute on chronic diastolic CHF”? Likewise, what should our coders do if the discharge summary indicates “malnutrition,” but the progress notes state “severe malnutrition”?
July 26, 2011
QUESTION: A patient in the hospital receives observation services with the diagnosis of orthostatic hypotension. The patient also has a history of hypertension being treated with Propanolol. Do we code only the orthostatic hypotension (code 458.0) or do we code both 458.0 and 401.9 for unspecified hypertension?
July 19, 2011
QUESTION: The medical record states that the patient is on Coumadin® and had cerebral hemorrhage secondary to Coumadin. Which ICD-9-CM codes are appropriate to report for this diagnosis?
July 12, 2011
Q: When should we use the seventh character "A" for a traumatic closed fracture in ICD-10-CM? Is it only for the first visit since it is for the initial encounter?
July 5, 2011
QUESTION: When a patient has pneumonia due to H1N1, should we report ICD-9-CM code 488.1x (Influenza due to identified novel H1N1 influenza virus) and an additional code for the pneumonia? Viral pneumonia with influenza codes to 487.0 (influenza with pneumonia) and 480.9 (viral pneumonia, unspecified).
June 28, 2011
QUESTION: A patient who is undergoing chemotherapy for cancer treatment comes to the office to make sure that he or she is healthy enough for it. The patient has no new symptoms and is not showing any signs of toxicity. Would you code this as a low medical decision-making or moderate?
June 14, 2011
QUESTION: A patient in the hospital receives observation services with the diagnosis of orthostatic hypotension. The patient also has a history of hypertension being treated with Propranolol. Do we code only the orthostatic hypotension (code 458.0) or do we report both codes 458.0 and 401.9 (unspecified essential hypertension)?
June 7, 2011
QUESTION: How should I report patellofemoral chondrosis?