Nursing Home/Assisted Living Facility

[Anne]

Hi,

Just need some confirmation on facility coding; doctor presents a facility log sheet with only the patients name and the E/M code, telling us to use the previous codes. If I remember correctly, I recall someone, someplace.... (my mind is scattered lately) that you should always defaut to the original pt diagnosis to a long-term facility... am I right or wrong?

Thanks in advance..

Anne

 

[Laureen]

That sounds scary to me on a several levels. When you say facility do you mean like a nursking home? If these are regular EM codes i.e.. not case management codes it seems you'd need to know the illness they were called in to evaluate/treat. I think we need more details to answer this properly.

 

[Anne]

I know it does Laureen. Yes, I am referring to nursing homes and assisted living facilities; our practice goes to both each day and I have always coded what the doctors were called told what the complaint was. However, the girl who is assisting me with billing was recently told that if the doctors do not put a diagnosis code, then you simply put whatever the previous visits diagnosis was. I have told that we have to query the doctor for all non-diagnosed patients, but that through my studies I have also learned that we should be documenting what the patient's initial admission was (e.g. Alzheimer's, dementia, etc)