What should you as the him director do

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Reference no: EM133412926

Case Study: An active practice of physicians specializing in infertility regularly admits patients to the outpatient surgical department. The practice contributes to a large volume of cases in the outpatient surgical department. The physicians regularly perform laparoscopies on many of their patients. The procedure can be performed to determine the extent of endometriosis that is causing the patient pain or determine the effect of the endometriosis in the patient's current infertile state. You are the new HIM director for the outpatient surgical program. You have come to realize that when the physicians document, they only ever refer to the endometriosis, even when supporting documentation by nursing staff repeatedly mentions infertility.

Questions:

What should you as the HIM Director do, as you are aware the documentation in the medical record does not accurately reflect the underlying reason for the procedure?
What would you do if the physician insists that only the endometriosis is coded, with no reference to infertility? Should you defer to the physicians on the issue knowing that physician documentation is the only source documentation that a coder may use?

Reference no: EM133412926

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