A provider documents Rheumatoid Arthritis w/positive rheumatoid factor (M05.9) in the A/P.
However in the EHR system the provider puts in the dx of Rheumatoid Arthritis w/rheumatoid factor of multiple sites w/o organ or systems (M05.79). This code does not reflect what the provider documented. Due to trying to capture HCCs would you send back to provider asking for them to be more specific in the A/P to put the verbiage needed to capture the code they want (which I find is leading the provider), or would you code the dx as it is in the A/P.

I have always coded the dx off of what the provider documents, and don’t rely on the “codes” the provider chooses (that hang out in a different part of the EHR for that encounter)

I’ve discussed with another coder who says the reason why to send back to provider is that we are doing concurrent review and need the documentation support for what the providers are trying to code in order to capture the correct HCC.

Any thoughts? Thanks

And how do you tell providers nicely that you change the dx if it’s not supported.