ICD 10 Coding Alert

Question: In your issue last month, you noted that if confusion exists in the medical record and the coder can’t determine the most accurate ICD-10 code, they should consult the physician. We have tried this in the past and one physician in particular seems annoyed every time we ask him for clarification. The reason we must approach him is due to lack of clarity in his documentation, but he seems very inconvenienced when we have to ask him about encounter details. How do other practices manage this?

Georgia Subscriber

Answer: One thing that practices find to work in this situation is to bring in a third party who can provide an education session for the entire staff (clinicians, billers, coders, and the rest of the team). This can be someone from an external billing service, a consultant, a trainer, or someone else. Have all participants share their potential issues with the educator ahead of time so they know the problems your individual team members are facing. This way, the trainer can address these topics without naming names, making people point fingers, or having people be embarrassed because some issues are clearly directed at them.

Instead of identifying specific culprits, the trainer can offer overall coding, documentation, billing, and communication advice that can address all the issues you’re having at the same time. This can allow your practitioners and coders to understand how to stem problems before they begin, and how to fix issues as they arise.