Wiki Amending codes

[PennyG]

We have just implemented a new EHR and Practice Management System. The EHR suggests codes at the end of the note. When my coders find a visit that they feel has been inappropriately coded based on the documentation, they have been messaging the provider and asking them to correct the codes at the end of the note. Of course, the providers are not happy with this work-flow.
My question is, would it be appropriate for my coder to amend the codes in at the end of the note with a statement to the effect that they have changed the code based on documentation? They would then alert the provider to the code change.

pennyg

 

[nyarborough]

It depends on who is being held responsible for the coding (in my opnion) if the providers are responsible, then the providers should make the changes. If the coders are ultimately responsibile, then the coders should make the changes. If a significant amount of changes have to be made to the coding, you may consider if that EHR function is effective for your practice.

EHR systems that select the codes, are template coding, yes based on guidelines - but template coding can not detect medical necessity. Example, based on template coding, a provider can write/dictate a level 3 H & P for a patient having cardiac chest pain AND a level 3 H & P for a patient presenting with a simple sore throat. The medical necessity is not the same, but if all the elements are met - would you feel comfortable with a level 3 for both?

Ultimately, at the end of the day, if the records were reviewed and audited, who would assume responsibility for those records - the provider or the coder - just something to consider.

You may consider added a "amending statement" stating that the changes were made by the coder and require a comment explaining the change - OR the provider can querried and have the provider justify the coding by amending the record - within a reasonable amount of time of course

Hope this helps

 

[mitchellde]

The coder is equally responsible for the correcteness of the code they select and put on the claim. I do not feel the coder shouls change anything in the medical record, but then I also feel you need to stop the EMR from selecting codes and appending them. The numeric code should not even be a part of the documentation. It is not a requirement that any number in the document match the number on the claim. The code may assign any code to the claim as long as that code is consistent with the naraative documentation. The coder does not require provider permission to change the code for the claim.

 

[dclark7]

The EHR we had at a previous employer also appended codes, but there was a statement at the end the said "The actual code billed may be different after review of records is complete."

However, I agree with Debra, the code should not even appear on the encounter documentation. If you can turn off that feature you should.