coding
If a patient is aftercare neoplasm surgery, and I know as a coder, that the neoplasm or hx of neoplasm should also be coded, am I as a "coder only" allowed to code the cancer without the clinician's approval?
I say no. I do not know if the surgery completely removed the cancer and it is a hx or if it is still currently treated, and I don't feel comfortable adding a dx code that could be incorrect.
I need assurance that I'm correct because a nurse, new to our agency, is insisting that I can do that automatically and should be doing it and is bringing the issue to my supervisor.
Please advise.
Brenda Hoss
Coder
[cid:TabithaLogo_433b2d03-534e-489d-b9c1-36650ed12d86.jpg]
Privileged and confidential: The information contained in this e-mail message is intended only for the personal and confidential use of the intended recipient(s). If the reader of this message is not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error and that any review, dissemination, distribution or copying of this message is strictly prohibited. Please notify us immediately by e-mail, and delete the original message any attachments, if any. Opinions, conclusions and other information in this message that do not relate to the official business of Tabitha Health Care Services shall be understood as neither given, nor supported, nor endorsed by Tabitha Inc.
I say no. I do not know if the surgery completely removed the cancer and it is a hx or if it is still currently treated, and I don't feel comfortable adding a dx code that could be incorrect.
I need assurance that I'm correct because a nurse, new to our agency, is insisting that I can do that automatically and should be doing it and is bringing the issue to my supervisor.
Please advise.
Brenda Hoss
Coder
[cid:TabithaLogo_433b2d03-534e-489d-b9c1-36650ed12d86.jpg]
Privileged and confidential: The information contained in this e-mail message is intended only for the personal and confidential use of the intended recipient(s). If the reader of this message is not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error and that any review, dissemination, distribution or copying of this message is strictly prohibited. Please notify us immediately by e-mail, and delete the original message any attachments, if any. Opinions, conclusions and other information in this message that do not relate to the official business of Tabitha Health Care Services shall be understood as neither given, nor supported, nor endorsed by Tabitha Inc.