Documentation used for outpatient Rehab ICD10CM Dxes coding
I have been trying to find official reference that states it is o.k. to code from both Medical Diagnoses given on Rehab Referral from Providers i.e., MD, FNP, PA, etc but also whether it is o.k. to also use the documentation by the actual licensed therapists of the treatment diagnoses they document in their Evaluation and Treatment Plans, Rehab Discharge Summary, etc. So many times the referral orders are so limited on what is actually being treated and more detail is given in the history and plans for treatment given in the licensed therapist notes.
Per my first link below from the APTA it states in the FAQ Understanding ICD10CM "In an outpatient setting do our codes need to match the physician's? No. Your coding needs to be as complete as you can make it based on confirmed information that you identify during the visit. You may use codes for signs or symptoms pertinent to the physical therapy services you provided -- codes that the physician may not have included". Being in an acute care hospital it is hard to break from the strict guidelines of using only Medical Providers such as MD, NP, FNP, PA, DO, etc documentation only, but do not want to continue to cut ourselves short on our coding a complete picture on our Outpatient Rehab encounters especially as hard as Medical Necessity is these days to prove the patient's need for treatment. In North Carolina we are a Direct Access State since the mid 1980's also so the only reason we get signed orders is because of the necessity per Payers Guidelines. Any help with this is Appreciated.
Pamela Riddle, RHIT, CCS
Coding Compliance Coordinator
FAQ: Understanding ICD-10 (ICD-10-CM)
Q and A from ICD-10 Coding Webinar
Per my first link below from the APTA it states in the FAQ Understanding ICD10CM "In an outpatient setting do our codes need to match the physician's? No. Your coding needs to be as complete as you can make it based on confirmed information that you identify during the visit. You may use codes for signs or symptoms pertinent to the physical therapy services you provided -- codes that the physician may not have included". Being in an acute care hospital it is hard to break from the strict guidelines of using only Medical Providers such as MD, NP, FNP, PA, DO, etc documentation only, but do not want to continue to cut ourselves short on our coding a complete picture on our Outpatient Rehab encounters especially as hard as Medical Necessity is these days to prove the patient's need for treatment. In North Carolina we are a Direct Access State since the mid 1980's also so the only reason we get signed orders is because of the necessity per Payers Guidelines. Any help with this is Appreciated.
Pamela Riddle, RHIT, CCS
Coding Compliance Coordinator
FAQ: Understanding ICD-10 (ICD-10-CM)
Q and A from ICD-10 Coding Webinar
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