Wiki Altering ICD-10s on medical record

[Jenishelley]

Good morning,
Currently I am a coder in a Primary Care clinic and have a question in regards to changing or modifying ICD-10s on a medical record. When is it acceptable for the coder to change/alter an ICD-10 within a patients medical record?
Example: procedure 93922, ABI. Provider uses I65.29 Carotid Artery Stenosis. Who may change the ICD-10 noted within the medical record to reflect I70.8, Atherosclerosis of other arteries, the Provider or the coder?

 

[sls314]

Good morning,
Currently I am a coder in a Primary Care clinic and have a question in regards to changing or modifying ICD-10s on a medical record. When is it acceptable for the coder to change/alter an ICD-10 within a patients medical record?
Example: procedure 93922, ABI. Provider uses I65.29 Carotid Artery Stenosis. Who may change the ICD-10 noted within the medical record to reflect I70.8, Atherosclerosis of other arteries, the Provider or the coder?

The key part is the documentation. What has the provider documented? I'm not talking about what numeric code the provider selected in the EMR. What diagnosis does the provider's verbiage actually substantiated?

The provider doesn't have to choose the code. (In fact, I would prefer if the physician didn't choose a code in the EMR at all. Many physicians are not well-versed in coding guidelines.)

You as the coder can assign the correct code that is supported based on the provider's documentation. Unless your office has some sort of rule that only the physician can change the numberic code, which IMO would be silly. The provider has more important things to do with their time than go in and choose a different ICD-10. Let the coders code, that's what I say!

 

[amyjph]

I want to make sure I am reading this correctly. A coder cannot document, change or make any entries into the patient's medical record. Or, are you talking about changing or updating a code in a billing system or superbill?