By Dr. Jon Elion, MD, FACC and Founder/President of ChartWise Medical Systems
June is Men’s Health Month, when we focus on prevention, detection, and treatment of disease in men and boys. As a cardiologist, it is tempting for me to use this platform to talk about heart disease. Instead, I have decided to push myself beyond that, connecting to my cardiology roots while shooting for some extra bonus points by mentioning coding and Clinical Documentation Improvement.
I saw a patient in the office for follow-up two weeks after an acute inferior MI caused by a right coronary artery occlusion (that would be ICD-10 code I2.11). Remember that the meaning of “initial” and “subsequent” for MIs has changed since ICD-9, where it referred to the episode of care. But under ICD-10, this office visit for the single MI within the previous 4 weeks did not get any special code modifier. As he was leaving, the patient asked me to check his PSA (the Prostate-Specific Antigen which is used to help detect and screen for prostate cancer). Apparently his family doctor normally did this, but it hadn’t been checked in a while. He called a few weeks later to tell me that his insurance company refused to pay for the PSA check, as the test is not indicated in the context of a follow-up visit after a heart attack. It would have been covered if I had documented our discussion and coded for an encounter for screening for prostate cancer (Z12.5). [See how I snuck in a mention of coding and Clinical Documentation Improvement?] [Read more…]