Wednesday, December 19, 2012
For offices, groups and health plans trying to develop coding compliance policies, there hasn't been a lot of information available. Recently, the American Health Information Management Association (AHIMA) has tackled the issue head on in Defining the Core Clinical Documentation Set for Coding Compliance. This useful article will help anyone tasked with creating a coding compliance policy. You can find a copy of this paper here.
Wednesday, December 12, 2012
Recently, we received the following question and follow up questions in the Coding@scanhealthplan.com inbox.
Then, we received a follow up:
Follow up Question:
The instructional notes for 250.40 say:
chronic kidney disease (585.1-585.9)
nephropathy NOS (583.81)
intercapillary glomerulosclerosis (581.81)
Kimmelstiel-Wilson syndrome (581.81)
But you don’t code all those things unless they are documented.
I hope that clarifies.
In response, the questioner indicated that they planned on coding cerebral atherosclerosis (437.0) because:
Multi-infarct(cerebrovascular) ( see also Dementia, arteriosclerotic)"
I don't believe I did a good enough job explaining why you wouldn't code something not documented. But the reality is that cerebral arteriosclerosis is not the only cause of vascular dementia, although it may be the most common cause. Multi-infarct dementia (MID), due to multiple strokes or TIAs, or mixed type due to MID and Alzheimers, or many other