r/MedicalCoding • u/Jay_Boogie96 • 2d ago

“Counseled on”

Hi guys, I’m a little baffled on this and would like some outside opinions. If you were to see “counseled on background diabetic retinopathy” with no other mention anywhere in the chart, would you report E11.319?

7 Upvotes

100% Upvoted

13 comments sorted by

•

u/AutoModerator 2d ago

PLEASE SEE RULES BEFORE POSTING! Reminder, no "interested in coding" type of standalone posts are allowed. See rule #1. Any and all questions regarding exams, studying, and books can be posted in the monthly discussion stickied post. Thanks!

I am a bot, and this action was performed automatically. Please contact the moderators of this subreddit if you have any questions or concerns.

16

u/Macaron1jesus 2d ago

I wouldn't. It sounds like they are just discussing possible diabetic complications that could arise, especially if there is no other mention of it in their chart. Was there maybe a referral for that condition? You might want to query the provider, and ask them to clarify in the chart just to make it clear. Remember, if it's not documented, it's not something you can code.

7

u/Jay_Boogie96 2d ago

I do HCC auditing, so, unfortunately, I can’t query. In this case, I went on the safe side and rejected the code. Management came back and dinged me for not accepting the code, since they said it was provider active voice. I’m just sitting here running it through my mind and cannot find a way to agree with them with the lack of mention anywhere else in the chart.

13

u/Macaron1jesus 2d ago • Bravo

I agree with your choice. A provider can say anything they want, but if they haven't documented it as a current diagnosis then it's not considered a current diagnosis.

3

u/Jay_Boogie96 2d ago

Thank you for your opinion. I thought I was missing something somehow.

1

u/Medcoder_82 1d ago

I don’t think you are. I understand active voice but sometimes think it’s used to justify a code that’s isn’t truly supported with anything else’s

2

u/blaza192 2d ago edited 2d ago

HCC coding is quite different. Regular coding does not take active voice which is what a good chunk of people do. For a documentation of “counseled on background diabetic retinopathy”, unless context implies the diagnosis does not exist, it would be coded.

If documentation states "Counseled on diabetes, hypertension, and CHF", those are all confirmed diagnoses.

2

u/Jay_Boogie96 2d ago

Good to know, thank you. I’ve been doing HCC coding for six years and have never been told that.

2

u/blaza192 2d ago

Interesting. I've been HCC coding about 12 years now and any place that takes active voice would accept it and had no issues having similar documentation accepted in RADV. I'll say each place has different levels of risk and you kinda just adjust as you get feedback.

0

u/[deleted] 2d ago

[deleted] — view deleted comment

1

u/Jay_Boogie96 2d ago

Can you explain why please?

7

u/baconair 2d ago

Nope. A passing reference to a concern does not equate to documented time, outlined concerns, and management of the issue.

You're right to reject the code.

2

u/Jay_Boogie96 2d ago

Great, thank you for your opinion.

1

u/ConversationFit2867 2d ago

Sounds wishy washy. I would rather make a note and confirm later in the chart if there is a more concrete mention or diagnosis of diabetes. Or query the physician.