Coding, Classification & Reimbursement

outpatient results

  • 1.  outpatient results

    Posted 12-14-2018 07:39

    Should you always wait on results before completing coding for xrays, bone scans, holter monitors, CT scan etc...or can we complete it based on the admitting diagnosis?

    If someone could give me some input on this that would be great!

    Thanks!



    ------------------------------
    Jeri Collins
    Team Lead of Medical Records/Inpatient Coder
    ------------------------------


  • 2.  RE: outpatient results

    Posted 12-14-2018 08:34
    You need to code the final diagnosis.
    If nothing is found, you code the admitting diagnosis as the primary one.
    You can find instructions in the ICD-10 guidelines section IV. Diagnostic coding and reporting for outpatient services

    ------------------------------
    Rivona Wasserman
    ------------------------------



  • 3.  RE: outpatient results

    Posted 12-14-2018 09:10
    Thank you!​

    ------------------------------
    Jeri Collins
    Team Lead of Medical Records/Inpatient Coder
    ------------------------------



  • 4.  RE: outpatient results

    Posted 12-15-2018 14:35
    Hi.  You do not have to wait for results.  You can code the symptoms as the reason for the diagnostic tests, if the results are not available at the time of coding.  Per the Outpatient Coding guidelines, section IV, ​K, , it states in part "For outpatient encounters for diagnostic tests that have been interpreted by a physician. and the final report is available at the time of coding, code any confirmed or definitive diagnosis (es) documented in the interpretation.

    ------------------------------
    Cheryl Anderson, CCS, CCS-P
    Coding Auditor
    ------------------------------



  • 5.  RE: outpatient results

    Posted 12-19-2018 09:54
    ​ Waiting for results is just a timing issue. It states "at the time of coding" so if you choose to wait to code a case, then at the time you are coding it you have the results.  Your organization can also have guidelines that state you wait 4 days to code certain patient classes to ensure you give the department time to complete their documentation and post their charges.

    ------------------------------
    Gail Toney
    RAC & Coding Audit Manager
    Sentara Healthcare Hampton Roads Hospitals and Albemarle Hospital glhill@sentara.com
    ------------------------------



  • 6.  RE: outpatient results

    Posted 12-17-2018 08:54
    ​The guidelines state you do not have to wait for the results as you can code using the documentation you have at hand. But I would caution you as coding is not only for reimbursement but research and statistics. I would find out how the organization uses the coded data to determine if you should wait for the results. We try to wait for the results since the coded data is an integral part of many decision making processes.

    ------------------------------
    Gail Toney
    RAC & Coding Audit Manager
    Sentara Healthcare Hampton Roads Hospitals and Albemarle Hospital glhill@sentara.com
    ------------------------------



  • 7.  RE: outpatient results

    Posted 12-18-2018 18:26
    Hi Gail. So, what are you saying?  Don't follow the ICD-10 cm Official Coding guidelines when you don't agree with them?  Statistics are collected in our state of California from ED charts, OP surgeries and Inpatient stays.   Results of lab, xrays and other ancillary services will be reflected in future visits like M.D visits, possibly OP surgery or endoscopies and hospitalizations later in time.

    The Official Coding guidelines were determined by the National Center for Healthcare Statistics, along with the World Health Organization and field tested by the AMA and the AHIMA and industry experts.  The NCHS and the WHO are very concerned with statistics.

    So, I will stick with following the Official Guidelines, otherwise we will have chaos in the coding world.

    ------------------------------
    Cheryl Anderson, CCS, CCS-P
    Coding Auditor
    ------------------------------



  • 8.  RE: outpatient results

    Posted 12-18-2018 19:32
    The guidelines don't tell you not to wait, it states to code the confirmed diagnosis if you have when coding.
    So don't code the symptom again. It doesn't make sense  to code a symptom and not to wait for the final diagnosis.
    I agree that different organizations have their own policies, but it is highly recommended to code the final confirmed diagnosis.
    It usually doesn't take more than a few days for a diagnostic report to come back.
    there are many reportable cases and you would miss many confirmed cases. One such example is the cancer registry.
    How do you end up with the right number of confirmed cancer cases without coding them.

    ------------------------------
    Rivona Wasserman
    ------------------------------



  • 9.  RE: outpatient results

    Posted 12-18-2018 19:52
    Biopsies fall under the SDS or OP surgery.  They should not be coded until the final pathology report, therefore cancer registry will have the most detailed  information for reporting cancers. Xrays and scans are a different story altogether.

    ------------------------------
    Cheryl Anderson, CCS, CCS-P
    Coding Auditor
    ------------------------------



  • 10.  RE: outpatient results

    Posted 12-19-2018 09:34
    How do you identify blood disorder cases, such as Leukemia? How about a patient having a fracture associated with bone cancer?
    A bone scan can show osteoporosis, a CT can show a major issue. I don't feel it is right just to leave it out.
    But you are right, you are not required to wait, so it is up to the hospital to decide.

    ------------------------------
    Rivona Wasserman
    ------------------------------