We have a quandary. Dr. says a patient has new compression fracture of the thoracic spine following a fall. Radiology exam shows only OLD fractures. With the new guidelines I know we can code a diagnosis based on the doctor's notes. However, if t do code according to the Drs. note. and the chart gets audited, I'm afraid it will all be denied based on no clinical evidence. I would appreciate any input on this issue.Thanks in advance.
That is a tough one. Wondering if you can provide some background info. What was the reason for patient seeking medical attention? Was it acute back pain? Was it to work up the reason for the fall? Is there any indication that the MD reviewed the results of the radiology exam? Was there an ortho or other specialist consult? Sometimes, the MD will disagree with the radiologists reading, so I'd look for other clues in the documentation. Sometimes they state that as per their read (this is not always done), they disagree with the radiologist. At my facility, the MD will copy/paste the pertinent info into their note, but on occasion, they may disagree with the findings, especially if an orthopedic/neuro/neurosurg MD is consulting- they will usually go with the specialist's assessment. But they would address that in the body of the note/assessment. If the attending states acute back pain due to new compression fracture after a fall and specifically notes the radiology findings, you may not need to query. However, if you are this uncomfortable with the situation, you may have to query for confirmation given the documentation discrepancy, especially if there is no reasoning in the attending MD documentation. Just my take.
Hopefully others will chime in as well.
Good luck on this one-
I would query MD to clarify conflicting documentation within the patient record, noting in the query his written diagnosis and the radiology report diagnosis.
Linnette Wert RHIT, CCS
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