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Have a coding or transcription question? Get an expert answer by sending an
e-mail to edit@gvpub.com.
This month’s selection:
A radiologist interpreted an abdominal ultrasound to read “consistent with gallstones, or suspicious for cholelithiasis.”
Can a coder use the referring/ordering physician’s ICD-9 code (abdominal pain) if the radiologist who dictated the report doesn’t furnish a definitive diagnosis? In my experience, if you are coding from the radiologist’s dictated report, you cannot use the referring doctor’s order to validate a diagnosis but instead use it as the symptom.
Brenda L. Melone, RN, CPUR, CPC
Rhode Island Hospital
Providence, Rhode Island
Response:
The Diagnostic Coding and Reporting Guidelines for Outpatient Services state that if a diagnosis is documented as “probable,” “suspected,” “rule out,” or other similar term indicating uncertainty, code the signs/symptoms, abnormal test results, or other reason for the test.
If the radiologist documented uncertain findings, it is appropriate to code signs or symptoms provided by the ordering physician. It is important to document the ordering physician’s reason for the test in the patient’s medical record. This is usually performed during the admissions process and included on the procedure request. If the ordering physician’s signs or symptoms contraindicate findings by the radiologist, it would be appropriate to query the ordering physician and/or radiologist for clarification.
— Jeff Pilato, MHA, RTR, CPC-H, is director of revenue cycle at HRS. |
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The Risks and Rewards of a Health Data Commons
An interview with John Milbanks, a senior fellow at the Kauffman Foundation and director of the Consent to Research Project, examines the risk and rewards of a health data commons.
Smart CFOs Keep Focus on ICD-10
Healthcare Finance News says smart chief financial officers are staying focused on ICD-10. |
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Kaiser Permanente Health Management App
Kaiser Permanente’s iOS health management app offers members access to the same tools they can use through My Health Manager on kp.org. Members can e-mail their providers, check lab test results, order prescription refills, and manage appointments. KP Locator, a facility locator app, is integrated into the new app. Users can input a city name or zip code to find Kaiser Permanente facilities in their area. The app is available free in the iTunes store. Learn more »
DoctorCom Healthcare Practice Management Apps
DoctorCom, Inc’s free HIPAA-compliant healthcare practice management smartphone apps for both the Android and iPhone platforms provide healthcare professionals with click-to-call, secure messaging, and file sharing with colleagues. The privacy features enable communications with colleagues and patients without compromising the privacy of personal contact information. The app also is integrated with the DoctorCom Answering Service, which provides a secure mobile solution for healthcare practice management that integrates with EMRs. DoctorCom’s answering service is a scheduling interface that ensures colleagues and patients always reach the right doctor. Messages are stored in a cloud-based solution for safe keeping and future reference. DoctorCom is free for credentialed healthcare providers.
Learn more »
eCareSoft App for Physician EHR
eCareSoft, Inc’s Android application for Nimbo ambulatory EHR is a streamlined practice management, EHR, and e-prescribing solution for single or multiple physician clinics. With this release, physicians can log into the tablet version of Nimbo from the hospital, home, or another facility and securely access vital patient information. Nimbo is a native mobile application with enhanced encryption technology to safeguard the integrity and confidentiality of the electronic patient data. Nimbo also integrates with eCareSoft’s Cirrus ONC-ATCB certified complete inpatient-hospital EHR. Both are software-as-a-service cloud-based solutions.
Learn more »
Skin Cancer Mobile App
A free app developed at the University of Michigan Health System allows users to create a photographic baseline of their skin and photograph suspicious moles or other skin lesions, walking users step by step through a skin self-exam. The app, UMSkinCheck, sends automatic reminders so users can monitor changes over time to a skin lesion and provides pictures of various types of skin cancers for comparison. The app guides users through a series of 23 photos, covering the body from head to toe. Photos are stored in the app and serve as a baseline for future comparisons. The app will create a reminder to repeat a skin self-exam on a regular basis. If a mole appears to be changing or growing, the photos can then be shared with a dermatologist to help determine whether a biopsy is necessary. The app also includes a risk calculator that allows users to input personal data to calculate individual risk. UMSkinCheck is designed for the iPhone and iPad and is available on iTunes. Learn more » |
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