"with" confirmation without physician approval

kphilp@newcenturyhospice.comkphilp@newcenturyhospice.com
in Home Care Coding General
May I ask how Coding clinics and others that are training are instructing Hospice and HH coders and non-coders to utilize "with" without the physician approval? As a CPC making this assumption without definite connection between the two conditions could be risky if audited. I realize there are a few difference of opinions. Trying to get some clarification on this topic. thank you

Comments

  • SusanWinokurSusanWinokur
    edited April 2017
    The instruction to code "with" does not override the requirement to verify all diagnoses and confirm orders for care with the physician.

    Susan Winokur, HCS-D, BCHH-C | Southwest Medical
    Part of OptumCare
    Senior Medical Coder, Home Health

    8655 South Eastern Avenue, Las Vegas, NV 89123 USA
    T    +1 702-838-0644
    Susan.Winokur@optum.com
    smalv.com
  • kphilp@newcenturyhospice.comkphilp@newcenturyhospice.com
    edited April 2017
    thank you all. My concern was linking "with" hypertension and Coronary artery disease(heart disease).

    Thanks again.

    Kathy
  • jamie.seghers@amedisys.comjamie.seghers@amedisys.com
    edited April 2017
    The assumption for with only applies when "with" is the first thing under the main term in the index. Then anything under that with has an assumed relationship to the main term.

    Thanks,
    Jamie Seghers, HCS-D, BCHH-C, COS-C, ICD-10-CM Certified Trainer
    Medical Coding Manager
    Office Phone: 225-299-3763
    Cisco ext. 3763
    Fax: 877-751-5987
  • jamie.seghers@amedisys.comjamie.seghers@amedisys.com
    edited April 2017
    That is correct as long as the physician has not stated a cause for the nephropathy you would code it as E11.21.

    Thanks,
    Jamie Seghers, HCS-D, BCHH-C, COS-C, ICD-10-CM Certified Trainer
    Medical Coding Manager
    Office Phone: 225-299-3763
    Cisco ext. 3763
    Fax: 877-751-5987
  • SusanWinokurSusanWinokur
    Agreed. Just don't go crazy looking for diabetic complications to code without verification from the physician. Otherwise, you could code all diabetes patients with cataracts as a diabetic complication... but you still need confirmation from the physician to support your coding.

    Susan Winokur, HCS-D, BCHH-C | Southwest Medical
    Part of OptumCare
    Senior Medical Coder, Home Health

    8655 South Eastern Avenue, Las Vegas, NV 89123 USA
    T
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