Q&A: Our providers don’t always document correlation between symptoms and diagnoses

Q: Our providers are reluctant to document a correlation between symptoms and a detailed diagnosis. Do you have any good ways to get them to do this? For example, our providers document "diabetes" but they often don't include additional details that should be there (e.g., gestational diabetes or Type 2 diabetes mellitus in pregnancy).

A: The best solution is to query the physician in order to get those details. Ask them to document the specificity and make sure the query is through paper documentation or email so you have a history of how and when you queried for legal purposes.

Then, meet with the provider face to face. That will give you the opportunity to educate them why these details are necessary for coding and compliance. When you actually talk to them and show them why it’s important to have this information, they’re more likely to listen.

This process also ensures that if facing an audit from CMS or other payers, you have the documentation to prove you put forth due diligence in getting the information and reporting the condition correctly.

Editor’s note: Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, and ICD-10-CM/PCS trainer is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist, with more than 20 years of experience. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog: http://lori-lynnescodingcoachblog.blogspot.com.