RE: "consistent with" diagnosis ???

[Priscilla Bullard]

There are 2 different issues being addressed here: Firstly, does the MD require an x-ray to diagnose a fracture? Secondly, are ‘rule-out’ diagnoses valid?   Regarding the first question: can an MD diagnose without a test (lab, x-ray) to support his diagnosis? This question has many grey areas- what is the practice setting? Does this diagnosis impact reimbursement? Are we talking about an MD’s scope of practice, or government requirements for reimbursement?  An MD has the ability to diagnose. Unless the diagnosis has specific reimbursement or diagnosis coding guidelines, if the MD writes it I code it. Remember also that just because it is coded in the medical record doesn’t mean it is coded on the claim.   Regarding the second question: there are different diagnoses coding guidelines for acute and non-acute settings. This is confusing, because a lot of the time they are referred to as in-patient and out-patient, and a SNF has patients!  This is the link for the Official ICD-9-CM Coding Guidelines:  http://www.cdc.gov/nchs/data/icd9/icdguide.pdf  .  See Section II, letter H, pages 48-49.   Then see Section IV, letter I, page 53.  I know this is confusing, but there IS A DIFFERENCE BETWEEN A LTC HOSPITAL and a SNF. LTCH have their own regulations (for example, see the Federal Register / Vol. 67, No. 169 / Friday, August 30, 2002 / Rules and Regulations ).  To put this in a nut-shell, a hospital can code a ‘rule-out’ dx, but a SNF can’t.    For the original question about the possible rib fracture: This would be captured on the MDS in J4. I personally would code the fall, and I would code J4d, ‘other fracture in last 180 days’. This MDS item does not impact reimbursement, and according to the original post the MD wrote “acute rib fracture”. I would also code (and care plan) the fall, the pain, etc.   I apologize for the long response.   Cil Bullard RN, CPC, RAC-C   -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Jennifer Russo Sent: Tuesday, February 17, 2004 4:57 PM To: [EMAIL PROTECTED] Subject: RE: "consistent with" diagnosis ???   I have nothing in writing. I am not a coder. -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]On Behalf Of MDSNancy Sent: Tuesday, February 17, 2004 2:27 PM To: [EMAIL PROTECTED] Subject: RE: "consistent with" diagnosis ??? Is this written somewhere?  I've been told by UMR that I can't use a "r/o" diagnosis. Jennifer Russo <[EMAIL PROTECTED]> wrote: It is my understanding that when an MD is "ruling something out" you code for what ever is being ruled out so I would code for the fracture especially since the MD has it documented and it is affecting her current status. -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]On Behalf Of MDSNancy Sent: Tuesday, February 17, 2004 10:22 AM To: [EMAIL PROTECTED] Subject: "consistant with" diagnosis ??? I have a resident who is on hospice services.  She apparently told the doctor that she fell, but not the nurses!!  No one saw it.   She is c/o of rib pain.  There was no xray done r/t hospice.  The doctor wrote in his progress note   "pain....  consistant with rib fracture".  and  "acute rib fracture".    Do I code these or not?????    General opinion here is not to code it without the supporting xrays, but wanted other opinions . Thanks! Do you Yahoo!? Yahoo! Finance: Get your refund fast by filing online Do you Yahoo!? Yahoo! Finance: Get your refund fast by filing online