I work in a large specialty clinic (spine and neurosurgery), and we have implemented use of EHR within the past year. We are preparing to transition to ICD-10 and are auditing notes for the diagnosis.
Our providers use a combination of Dragon dictation and point and click to document the visit. The HPI is usually dragon dictation (which can sometimes be a real mess) and they usually dictate everything here, whether its the current symptoms, recent diagnostic results, etc. Exam is all point and click. The assessment and plan is point and click and they are choosing a diagnosis with an ICD-9 code that may or may not always be correct and there is NO narrative under the A/P section at all - it is only computer-generated terminology that they have picked from a list. So we end up with diagnoses like 724.02, lumbar stenosis, that they select to add to the A/P, but more times than not, we have no narrative from the doctor regarding the implications/reasoning for this diagnosis.
Here are my questions:
1. If all I have to go on is the diagnosis they picked from the computer-generated list, can I code based on that alone, or would it be better just to code any related signs/symptoms (i.e. low back pain)?
2. Also, if they were to mention the recent MRI (as read by the radiologist) showed L4-5 stenosis somewhere up in the history, can I use that to code 724.02, lumbar stenosis?
3. For auditing purposes for ICD-10 readiness, since we are trying to see if they are documenting to the highest level of specificity, should I code on one single note alone, or can I refer back to previous notes in the chart? (i.e., stenosis documented in the past, but they just carried the diagnosis over to this visit since the patient is in for a followup)
Many thanks for your input. I am still learning to swim the waters of coding/auditing!
Our providers use a combination of Dragon dictation and point and click to document the visit. The HPI is usually dragon dictation (which can sometimes be a real mess) and they usually dictate everything here, whether its the current symptoms, recent diagnostic results, etc. Exam is all point and click. The assessment and plan is point and click and they are choosing a diagnosis with an ICD-9 code that may or may not always be correct and there is NO narrative under the A/P section at all - it is only computer-generated terminology that they have picked from a list. So we end up with diagnoses like 724.02, lumbar stenosis, that they select to add to the A/P, but more times than not, we have no narrative from the doctor regarding the implications/reasoning for this diagnosis.
Here are my questions:
1. If all I have to go on is the diagnosis they picked from the computer-generated list, can I code based on that alone, or would it be better just to code any related signs/symptoms (i.e. low back pain)?
2. Also, if they were to mention the recent MRI (as read by the radiologist) showed L4-5 stenosis somewhere up in the history, can I use that to code 724.02, lumbar stenosis?
3. For auditing purposes for ICD-10 readiness, since we are trying to see if they are documenting to the highest level of specificity, should I code on one single note alone, or can I refer back to previous notes in the chart? (i.e., stenosis documented in the past, but they just carried the diagnosis over to this visit since the patient is in for a followup)
Many thanks for your input. I am still learning to swim the waters of coding/auditing!
Auditing Diagnoses in EHR
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