Diagnosis Coding — When You Can and Cannot Code the Diagnosis

Diagnosis Coding — When You Can and Cannot Code the Diagnosis


One of the questions that we get from new
students is knowing when you can and cannot code the diagnosis. I think a lot of students, as soon as they
learn how to look up codes, they are ready to code everything that they see. And every new student does it. I remember I did it. I wanted to call myself a supercoder because
I wanted to code everything. Itís fun to code. But you canít do that. You need to code only definitive diagnoses
and they can be hard to identify. One of the things that you have to stay away
from is equivocal language. When we say equivocal language, that means
itís kind of on the fence. Itís not a definite. It can go one way or the other. You have to stay away from that type of verbiage. Impending or threatened conditions, youíll
see that, but that can be tricky. You cannot code something if it has not happened
yet, in most cases. Now I know that sounds again, a little ambiguous,
but if your physician documents, for example, weíll scroll down here just a bitÖ impending
rupture of spleen due to enlarged spleen. Okay, impending tells you itís going to happen. Theyíre pretty sure itís going to happen
but it hasnít happened yet. So you cannot code a ruptured spleen. You can only code the splenomegaly which is
an enlarged spleen, 789.2. Thatís the proper code to use. Now Iíve got some more examples for you,
so weíll scroll down and look at some of these others. Okay if your physician documents something
like this ñ Mrs. Jones is seen today with lower abdominal pain and spotting. I will admit her for a threatened miscarriage. So youíre now saying to yourself, ìWell,
she hasnít had a miscarriage. It hasnít happened yet.î But in actuality,
thereís a code for this because itís such a common event. You can, however, code 640.0 and youíll need
a fifth digit. It does not matter that the miscarriage has
not occurred yet. There is a code for a threatened miscarriage
because that is a medical condition. If there had not been a code for that then
you would have to code the signs and symptoms, just the spotting and the abdominal pain. Okay, weíve got some more things to look
at here, words that you want to pay attention to. “Possible, maybe, suspect, rule out, probable,
expect, apparent, perhaps, conceivably, plausibly”. Now if youíre coding and youíre coding in
an office that you have repetitious documents from specific doctors and you see them all
the time, youíll learn what verbiage they use. But if youíre doing something like remote
coding or multiple physicians, it may be a little harder and you have to kind of get
to know how they like to document, how they like to word things. These are some words that just popped up in
one day of remote coding that I was doing and it gets to be kind of humorous sometimes
where you have to do a second take and say, ìWhat did they say? They said maybe?î
So scroll down just a little bit more. Iíve got some more examples. Okay, these terms mean your physician does
not know or is waiting for more testing. If the statement is made, this is another
little case ñ Mr. Green has been feeling tired, thirsty and is making frequent trips
to the bathroom. Itís apparent he has DM since his father
and mother both had DM by age 50. We will draw labs today. He is to return in one week for the results. Now, the fact that he said itís apparent
he has diabetes, he didnít actually say that he has diabetes. He said itís apparent that he has diabetes. And then he confirms that heís not sure because
heís going to do a test and have him come back for the results. You have to be very careful. If you gave this gentleman diabetes with the
way you coded, itís going to follow him for the rest of his life. And he could have problems in the future,
maybe even getting jobs or life insurance policies because they do look at your medical
information to determine stuff like that. So you have to be very, very careful. He might just have a bad cold and be real
thirsty. Okay so another example. Mr. White is seen today with some ascites
and a chief complaint of dyspnea. He stated that he had been waking up at night
with a dry cough. He has a history of CHF and microvascular
spasms. This is probable for cardiomyopathy. Physical exam reveals mild ascites, tachycardia,
peripheral edema and cool extremities. Previous diagnostic testing wasÖ scroll down
just a little moreÖ was reviewed, was confirmed cardiomyopathy and tell, he said, which confirmed
cardiomyopathy. Youíre not allowed to code that because he
doesnít have it until he stated, he confirmed why he was suspecting cardiomyopathy. But all the verbiage before that was all suspect. So pay attention to the details and your documentation. Donít ever jump to conclusions and itís
very hard when you first start out, not to jump to conclusions. Itís going to get you in trouble when youíre
testing especially because some of those questions are specifically written to see if youíre
paying attention. I know if I wrote a test question, thatís
like throwing in not in a test question. How many people are not feeling well today
or something like that? So pay attention. Those little words will catch you. Laureen: Alright. Okay, next one is for me. This hadÖ we actually had last month but
we didnít have time to get to it. SoÖ and then we got another question related
to it so we kind of put them together on the same slide regarding E&M guidelines for 95
versus 97. The first person wrote, ìI see EM guidelines
95 and 97 used in prep test for the CPC. Can you explain what these guidelines are?
Iím not sure what these are.î And then number 2: ìCan some doctors in our
hospital like general practitioners and internal medicine doctors document their outpatient
visits according to 1995 guidelines and at the same time, general surgeons, urologists,
OBGYN, eye and ENT specialists document their outpatient visits according to 97 guidelines? So ultimately, when the external audit occurs,
how do theseÖ how these charts can be audited according to 95 guidelines or 97?î So letís take a look at the answer sheet
I prepared. Laureen: Yeah. So what I did is I took a screenshot of my
actual manual because I do like you know, when I teach everything, to take you right
to the book versus just typing a whole bunch of stuff on a slide. So you can really see things in context. So in your CPT manuals, you have this in the
E&M guidelines and thereís this step here, ìDetermine the extent of exam performed.î
I have it labeled number 2 because the first step is figuring out the history. And thereís 4 levels in the CPT manual and
this way of doing E&M came about in 1992. So if youÖ donítí really call it 92 guidelines
but just to give you a little history, thatís when it started. So theyíve got 4 scores that you can have. 4 scores? Never mind. Problem focused, expanded problem focused,
detailed or comprehensive. Now, part of my technique when Iím teaching
E&M is I teach you to convert these phrases to one letter so P,E,D,C ñ problem focused,
expanded problem focused, detailed, comprehensive. So this is what doctors had to first start
with. Prior to that, they were just coded by time. ìOh, 10 minutes? Itís a level 1. 20 minutes is a level 2.î The higher the
level, the more money. So they came up with these guidelines and
this is the problem. If youÖ problem focused is easy. Itís a limited exam of the affected body
area or organ system. So if they come in with pain in their knee,
well the doctor isnít going to do a full workup. Theyíre just going to focus on their knee. So that will be problem focused. Expanded problem focused, itís a limited
exam of the affected body area or organ system and other symptomatic or related organ system. So I call it a limited plus. So itís that one organ system, the reason
they came in, and maybe one more. For example, if a patient comes in with a
headache, it could be stress related or could be something very serious like a tumor. So they might do a neurological type of questions
and look at a couple organ systems to try and figure out what theyíre dealing with. Then a detailed level of exam is an extended
exam of the affected body area and other symptomatic or related organ systems. This is almost word for word the same as expanded
problem focused. But the only difference is limited versus
extended. Thatís really the only difference. And then comprehensive is a general multisystem
exam or a complete exam of one organ system. So the problem focused is easy. The comprehensive is easy to figure out. But doctors were like, ìWell, how do I know
limited versus extended?î Thatís kind of nebulous. So thatís when they came out with the 97
guidelines. So what we just read here is basically the
95 guidelines , without going into a whole 3-hour E&M lecture. Youíve got your 3 key components: history,
exam and medical decision-making. The difference between 95 and 97 guidelines
is primarily dealing with this exam issue. There are a few little nuances of difference
in the history and medical decision making but a bulk of it is what we just discussed. Okay so thatís kind of like the 95 versus
97. And when they talk about body areas or organ
systems, theyíre listed right in CPT for you. So here are the body areas: head, neck, chest,
abdomen, genitalia, groin, buttocks, back, each extremity. So what you want to understand here since
weíre talking about it is these bullets are kind of literal. So if you have each extremityÖ so the right
arm would count as one bullet or if you were doing an audit, youíd have aÖ your little
check box. Left arm, one checkbox. Right leg, one checkbox. Left leg, one checkbox. So each extremityÖ so this could be up to
4. But chest, including breast and axilla, if
all 3 of them are looked at, this just counts under this one bullet. And then organ systems are here, eyes, thatís
one bullet. Ears, nose, mouth and throat all count as
one bullet. Itís not 4 different things. It counts as one bullet for adding up the
exam stuff. So I just want to give you that little tidbit
there. Another website that I like to use a lot is
EM University and let me take you there. emuniversity.com and the link is /physicalexam.html. [Ed. Note. http://emuniversity.com/PhysicalExam.html
] And they go in and they talk about the difference between the 95 and 97 guidelines. Now what happened with the 97 guidelines when
they saidÖ well, I donít know the difference between the limited and extended. The 97 guidelines came along and for certain
specialty areasÖ I donít know if theyíre listed here or not. Here we go, no thatís not it. But thereís a general multisystem exam for
97 and then thereís one for like psychiatry. Thereís one for cardiology. And so when youíre a physician in that specialty,
you could choose to use the 97 guidelines very detailed. And you have to add up so many bullets and
get your score to go back to that.. to back intoÖ was it problem focused, expanded problem
focused, detailed or comprehensive? Now the questioner was asking, ìCan you use
both? Can you mix and match?î And the answer is
yes. Youíre allowed to use whichever guidelines
to give you the best outcome. Let me go back to the question real quick. So on the board exam; they donít go into
too much detail with the 97 guidelines, not for the CPC exam. Now if youíre sitting for the E&M Specialty
exam, yes. You bring your audit tools and you do all
those little check box thingies. For the CPC exam, the CPC-H exam, theyíre
testing you more whatís on the CPT in the CPT manual. And they try and stay away from these real
grey areas so theyíll tend to use things like the general multisystem exam so you could
go, ìOh okay, thatís comprehensive.î And you can plug it in. But it isÖ you should understand generally
that there are these different guidelines out there. Youíre allowed to use whichever one is best
for you. So if you get a higher level using 95 versus
97, you can go ahead and code based on that. And then for the second question, yes absolutely. You can have some using 95 guidelines, some
using 97. Youíre totally allowed to do that. The intent was to have the 97 supercede the
95 but that didnít happen. It didnít work out that way. And theyíve tried to come up with new guidelines
ever since and that kind of failed. But a lot of what really drives it is the
medical decision making. And they do want to come up with a new system;
I just donít know how long itís going to be before they can do that. Okay so I think I covered everything on my
slide here. Oh and for those in the Replay Club, theyíll
get this answer sheet. You can go right to the official 95 and 97
E&M guidelines just to give you an idea of what it looks like. Itís cms.gov and theyíve got this outreach
and education Medicare Learning Network thing. And this is a PDF so you can print it but
itís very long. But what I did when I first learned this is
I printed out, I put it in a binder and I had my 95 and my 97 guidelines. But these are the official guidelines on the
CMS website. In addition, theyíve got this Medicare Learning
Network EM Guide. So if youíre kind of new to learning E&M
coding, this is a nice, detailed primer if you will on E&M coding given by CMS. And theyíve got some pretty good education
material. I donít know why this has taken so long. Laureen: So thatís the E&M guidelines, 95
and 97. Thatís a real rush job. Someone in the chat was asking if we have
training on E&M. Yes, we do. We have an on demand E&M class. Itís 3 hours. Itís worth 3 CEUs and we kind of go into
this in a little more detail. So you can check that out on the website.

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