I am really trying to get a grasp on my coding education...with that being said, I am a transcriptionist who works for a physical therapist who own/operates his own clinic. Part of my job is to make sure the dictation transcribed matches the diagnosis. Part of the problem I am having is that he, the PT, is only allowed to use certain codes...for example, if a patient comes in and had a fracture, the clinic is only allows to use codes for treating the pain..not the fracture because they are not treating the fracture...that is easily enough defined and I understand that...but another example is...patient came in with code on RX as being 'benign paroxysmal positional vertigo.' The physical therapist found that the patient had no vertigo symptoms...at best a vestibulo-occular vertigo possibly related to cervical dysfunction....the lady who does billing and I went with the BPPV code to be on the safe side....I wanted to put vestibular neuritis as the ICD 9 gave that as a reason for "vertigo for an unknown reason." What's right and what's wrong? One reason we are told to be careful is that the physicians' get upset if we change their codes 'implying the PT knows more than the MD..." Oh brother....anyhow, can someone help me see the light here...I am in the last half of module IV and really feeling like I am not getting it...Really wanting that light bulb moment....Thank you for any insight...wisdom...it really is appreciated.
The best thing to do in situations like this is to follow the coding guidelines and be sure to code only what is documented by the provider. If the documentation is unclear or conflicting then a query would need to be sent to the physician or in this case the physical therapist.