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Our Mission:
The Provider Education Department is committed to the
continuing development of ongoing education initiatives, with
a focus on maintaining the integrity of the Revenue Cycle.
Through multiple educational mediums, standardized to meet
requirements for each specialty, we strive to deliver cutting
edge educational materials to enable agile response to
healthcare industry regulation changes.
Excellence through education and experience
Diagnosis Documentation Training
Peninsula Regional Medical Center
10/27/2014
Presented by: Orlando K. Rodriguez, CPC
1
I. Diagnosis Documentation Review – Paper
II. Diagnosis Documentation Review – Electronic
III. Diagnosis Documentation Guidelines
IV. EGD, & Colonoscopy Documentation
V. Screening Colonoscopy Documentation
VI. Diagnostic vs. Screening Colonoscopy
Documentation
VII. Take Home Message
VIII. ICD-10 Sample Documentation
IX. Quality Satisfaction Survey
X. Questions and Answers
Diagnosis Documentation ReviewInvalid Documentation Samples
Paper Template
Diagnosis Documentation Review
Electronic Template
Pre-EvaluationHospital Face Sheet Intra- Op Record
Invalid Documentation Samples
Diagnosis Documentation Guidelines
Using a proper specific diagnosis description is necessary on Medicare, Medicaid,
and all other private insurance payers’ claims because the codes documented on
the anesthesia record will be used to assist in determining coverage and payment
amounts.
The documented diagnosis is also used in statistical collections by the insurance
payers to classify morbidity and mortality information.
In order to meet International Classification of Disease (ICD-9), CMS, and
private ins. payer’s coding guidelines, the following coding rules apply;
1. Use the ICD-9 code/description that describes the patient’s
diagnosis, symptom, complaint, condition or problem. Do not
code suspected diagnosis.
2. Use the ICD-9 code/description that is chiefly responsible for the
item or service provided.
3. Assign diagnosis descriptions to the highest level of specificity.
EGD & Colonoscopy
Documentation
Screening Colonoscopy DocumentationScreening Colonoscopy
Documentation
Per ICD-9-CM, CMS (Center for Medicare and Medicaid Services) and also
adopted into a written policy by several other commercial insurances, if the
indications for the colonoscopy is for “screening purposes,” then the
following documentation and coding guidelines will apply;
1. Indicate the primary diagnosis for the screening examination as the first
listed diagnosis (example: Screening for Malignant Neoplasm—Colon).
2. Indicate the secondary diagnosis as the abnormal finding (example:
polyp, hemorrhoids, etc.).
3. Document if the Colonoscopy was performed with a biopsy.
4. The testing of a person to “rule out (R/O)” or confirm a suspected
diagnosis because the patient has some sign or symptom is a
diagnostic examination, not a screening.
5. “ Normal” in the description of the diagnosis will not be acceptable for
coding/billing purposes.
Screening Colonoscopy Documentation
X
X
X
Example:First listed diagnosis = Special Screening for Malignant neoplasms,
Colon (ICD-9 - V76.51)Second listed diagnosis = Benign Neoplasm of Colon Unspecified or
Polyp ( ICD-9 -- 211.3)
Diagnostic vs. Screening Colonoscopy Documentation
Per the American Gastroenterological Association (AGA), a Diagnostic
colonoscopy is a test performed as a result of an abnormal finding, sign or
symptom (such as abdominal pain, bleeding, diarrhea, etc.). Medicare and
most payors do not waive the co-pay and deductible when the intent of the visit
is to perform a diagnostic colonoscopy.
A screening colonoscopy is a test provided to a patient in the absence of
signs or symptoms. A screening colonoscopy is a service performed on an
asymptomatic person for the purpose of testing for the presence of colorectal
cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does
not change the screening intent of that procedure.
Family history of malignant neoplasm of the GI tract or personal history of
colonic polyps may be considered as screening by most insurance carriers.
http://www.gastro.org/practice/coding/coding-faqs-screening-colonoscopyLINK
A diagnosis description of “normal,” C/O, or “R/O,” is
not used for billing purposes.
Communicate with the surgeon to obtain the pre and
final/post-operative diagnosis.
When the procedure’s findings is “normal,” please
document the indication(s) for the procedure (e.g.
rectal bleeding, A-Fib, etc.) The indication will be
used as the primary diagnosis for billing purposes.
If the colonoscopy procedure was unsuccessful due
to poor prep, the indication for the procedure must
be documented along with the “unsuccessful / poor
prep” description.
An anesthesia record with ONLY a diagnosis
description of “normal,” “R/O,” or “Unsuccessful” due
to “poor prep;” will be returned to the provider for
correction and an amendment will be required on the
record.
Diagnosis Documentation Guidelines
ICD-10 Documentation
Diagnosis Documentation Requirement Final ICD-10 Diagnosis description Examples
HX of Colon Polyps• Must document if it was related to a; 1. Family History
2. Personal History
EX 1: Family history of colonic polyps
EX 2: Personal history of colonic polyps
Appendicitis
• Must document if Acute, Chronic, or Recurrent
• Must document if it is with or without ; 1. Generalized peritonitis
2. Localized peritonitis
EX 1: Acute appendicitis with generalized peritonitis
EX 2: Acute appendicitis without localized/generalized peritonitis
Hernia
• Must document type/location of hernia (e.g. inguinal, etc.)
• Must document laterality (Unilateral or Bilateral)
• Must document if recurrent or not specified as recurrent
• Must document if it is with or without; 1. Gangrene
2. Obstruction
EX 1: Unilateral inguinal hernia, with obstruction, without
gangrene
EX 2: Bilateral inguinal hernia, without obstruction or
gangrene
Hemorrhoid
• Must document the type; 1. Hemorrhoidal
2. Residual
• Must document the severity/grade ; 1. First Degree
2. Second Degree
3. Third Degree
4. Fourth Degree
________________________________________________________
First Degree = Hemorrhoids (bleeding) without prolapse outside of
anal canal
Second Degree = Hemorrhoids (bleeding) that prolapse with
straining, but retract spontaneously
Third Degree = Hemorrhoids (bleeding) that prolapse with
straining and require manual replacement back
inside anal canal.
Fourth Degree = Hemorrhoids (bleeding) with prolapsed tissue
that cannot be manually replaced.
EX 1: Second degree hemorrhoids
EX 2: Internal hemorrhoids, without mention of degree
EX 3: External hemorrhoids with thrombosis (perianal
venous thrombosis)
Sample Documentation Requirements for ICD-10
Provider Education Quality
Satisfaction Survey
As part of our continuous commitment, you will receive a survey via email after each educational
session to rate its quality and usefulness . Considering your busy schedules, you can expect to
receive a weekly reminder.
The survey consists of 4 questions and an open ended question for additional comments.
Surveys are anonymous and responses to the survey are considered confidential.
Individual responses are not released, shared or published.
The main areas we evaluate are:
1. Speaker’s Performance
2. Education Materials
3. Presenter’s Knowledge
4. Information Usefulness
Instructions and website link are included on the survey invitation email.
OP
S &
RC
MC
OD
ING
CO
MP
LIA
NC
EQ
UA
LIT
YS
YS
TE
MS
UP
DA
TE
S
15
Orlando K. Rodriguez, CPCProvider Documentation Education Manager
954-514-4820
855-809-6975
