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If you have abdominal pain aka groin or flank pain, if the documentation does not specify any location at all, then you have no choice but to do two things:

1) The person taking down the information needs to learn to ask more questions and the doctor must also do the same thing as well as document the answer. I see too much of this with poor documentation. How can you code something when all that was documented is: "The patient complains of abdominal pain". Could it hurt to ask more questions like, show me where you are having the pain? The staff and provider must understand that poor documentation can hurt the provider in the pocket as well as in a court of law. "Doctor Jones, did you ask the patient any questions about their abdominal pain? yes I did. "Can you show me the questions you asked and the patient's response?" Well, it's not there, but I did ask those questions. Doctor, you can't really prove you asked any questions at all can you? No. "We, the jury, find for the plaintiff in the amount of $10,000,000 and the amount of $50,000,000 in punitive damages. The only reason that doctor could not obtain the specific information about the abdominal pain is if the patient was unconscious or spoke a foreign language and the doctor has no interpretor and these are clearly documented. Otherwise, if the patient can speak and speak the same language as the doctor, the doctor can easily ask, "Show me where you are having this pain" and then document the location.

2. You can send the chart back for an amendment of the medical record so you can code the claim better.

You should not use an unspecified code if it is clearly documented that no other code is possible. Piss poor documentation is not an excuse for selecting an unspecified code.

I performed an audit of more than 50 charts for one physician that was sending claims and all 50 claims were for a 99214. The first thing I saw on all 50 charts was the same thing: "The patient is here for follow-up" That's it, nothing more. You would think they would document more such as the reason for the follow up, when the patient was seen last and more. Next, there was no review of systems. Basically the history was never documented. Then came the examination. It was identical for all 50 patients. All 50 patients had a temp of 98.6, even those with a diagnosis of "fever". Every examination had the same identical spelling errors. Every examination had the same findings. A patient with cataracts had no abnormalities and their pupils were equal and reactive to light. A patient with a diagnosis of a toe fracture had no reddness, no swelling and no pain. A patient with leg amputations had peripheral pulses. What happened was they were caught using a cookie cutter medical record. The only thing changed was the diagnoses and even then these could not be justified. How can a patient have HIV when there were no tests ordered and reviewed? How can they diagnose a fracture of the radius with no x-ray taken or reviewed.

ICD-9 789.00, unspecified site, should not be used unless there is documented evidence that the patient was unable to provide exactly where they are having pain. Unspecified simply means the patient can't tell you where and that is only when the patient can't speak or speaks a foreign language with no interpretor. ICD-9 789.09, other specified site should be used only when the location of the pain is documented that the pain is of a specific site that is not that of those listed in 01-07. Generalized site means all over. So, you don't have much left when you eliminate upper left, upper right, lower left, lower right, umbilic or epigastric.

Just like JD Marriott used to say when opening a new business: Location, Location, Location. Documentation of "Patient complains of abdominal pain x 3 days" is unacceptable for coding this condition. This has foundation in the HCFA 1995 or 1997 E/M documentation guidelines because one of the HPI items is: Location.

Simply documenting "abdominal, groin, or flank pain" without any location is unspecified. (789.00)

Documenting "patient complains of pain in all sectors of the abdomen", that is generalized. (789.07)

Other specified site (789.09) has to be specific, but, as I said, I don't know what's left when you have the abdominal sites documented: Overall, upper, lower, right, left, umbilical, and epigastric.

Coders should not use unspecified codes when possible. They delay or deny claims. Coders should use unspecified codes only when the documentation shows the reason why more information could not be obtained. More and more doctors are being held accountable for their lack of proper documentation.

Oh, just FYI, our postings are not personal. We post generalized information so that other people who have the same problems can read them.