Re. inpt. coding

lkpengel

I am wondering what others do for coding M1017 when codes are clearly wrong from the inpt. setting. For example---d/c paperwork has wounds coded as traumatic while they are not. They fall under the E11.622 with non-pressure ulcer codes following. Do you use the codes from the referral in M1017 or the codes that will go in M1021/23?

Thank you!
Lisa

SusanWinokur

Always code from the physician documentation.
When patients are admitted for elective procedures, the hospital admission face sheet has codes provided by the referring physician office. Inpatient coding on the History and Physical and Discharge Summary are entered by someone working off a charge sheet. The final inpatient coding is done after a thorough review of the discharge record - probably not before the patient starts homecare service.

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

lkpengel

Thank you but I'm still a bit confused. The "Home Health Care Services Referral" signed by the MD has incorrect coding. Isn't this possible? I see it quite frequently with certain offices. And my mistake, it was NOT the d/c summary but the requisition for HH.

SusanWinokur

Query the physician to verify the correct diagnosis.

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

lkpengel

Ok, sounds good.