Coding, Classification and Reimbursement

Utilizing outside records for specificity

  • 1.  Utilizing outside records for specificity

    Posted 01-28-2019 10:04
    ​I am looking for clarification on utilizing scanned records from a transferring hospital for specificity. We have a case where the patient had a traumatic SDH presented to another hospital and was transferred to ours for continued care. There was no mention in our record of LOC, there are scanned records from the transferring hospital that stated there was no LOC. Can this information be utilized for specificity to code the SDH to without LOC? Is there references to support this? Or since there is no mention of LOC in our record should the default code of SDH NOS (SDH w/ LOC of unspecified duration) be coded instead?

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    Laura Haskell
    Ip Coding Supervisor
    Lee Memorial Hospital
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  • 2.  RE: Utilizing outside records for specificity

    Posted 02-01-2019 21:10
    I believe you should only code from the documentation generated from your own facility.  I want to say there is a Coding Clinic regarding not coding from outside documentation, but I can't tell you for sure.

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    Alicia Kellogg, RHIT
    Inpatient Coder
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  • 3.  RE: Utilizing outside records for specificity

    Posted 02-02-2019 10:48
    I agree with Alicia.Coding Clinic for ICD-10-CM and ICD-10-PCS First Quarter 2015 (p. 15) states, "[D]ocumentation for the current encounter should clearly reflect those diagnoses that are current and relevant for that encounter."  See the article "Use of previous encounter documentation to determine 7th character selection." See this article for further details.

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    Judy Bielby
    Consultant and educator
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