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Discussion

OASIS SOC vs Progress Notes

When you are doing an SOC, is the MD providing you with coded Dx to use?

Or do you have to dig through the FTF and unscramble the handwriting under whatever heading the MD is using so you can add additional "pertinent diagnosis" to the OASIS form?

Or does your QA do that part?

I ask because I get a combination of these and I recently had a nicely done FTF (printed! no handwriting!) with 5 coded diagnosis listed in order. Both the progress notes of the MD and my own Assessment noted that the patient was depressed. There was no formal diagnosis of Depression however.

Once the OASIS went through the coder, I found a Diagnosis for 311 DEPRESSION listed with the other Pertinent Diagnosis!

The coder insisted that since it was in the MD progress notes it could be used.

I explained that a report of "depressed" and my own assessment that the patient was depressed was not the same as an MD diagnosis of Depression.

I called the MD for clarification and they agreed with me. There was no diagnosis of Depression for this patient at this time. When I explained to the coder that the MD had JUST TOLD ME THERE WAS NO DIAGNOSIS FOR DEPRESSION, he still refused to remove it!

My DON even tried to justify leaving it in!

Months ago the same coder tried to explain "what Medicare likes" and mentioned how Medicare "likes" to have as many diagnosis as possible. I am unable to corroborate this with any other source.

Why? What incentive is there to add as many diagnosis as possible?

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