Wiki Audit question report vs claims

[SpaceTG]

Hi,

I am being told by a medical software that we can get fined for our claims not matching reports. Basically if I do a claim correction or I need to make a correction for a diagnosis and send a corrected claim but the report is not updated we can get in trouble. This for example is for an ICD that BCBS does like with a specific CPT but indeed is an issue so we do not remove from report because this is a diagnosis for patient but we correct claim by removing that 1 icd10 and leave the others. I have never use a EMR that makes you rely of providers to do billing and then just work on corrections and rejections afterwards and their defense is they are the highest compliant software. I would really appreciate anyone who knows about this to confirm this is true. I dont know how so many other EMR would allow you to make changes prior if it was not allowed.

Carla

 

[csperoni]

1) Anything said by any salesperson should be taken with a grain of salt. Their job is to get you to purchase their product.
Whether or not you are billing compliantly depends on a lot of nuances. Your patient records must contain what the patient's actual diagnosis is. It is fine if your system happens to assign an ICD-10 to that. However, it is not wrong, and you would NOT BE FINED if the clinician entered "N83.209 Unspecified ovarian cyst, unspecified side" and the bill was corrected to "N83.291Corpus luteum cyst of right ovary" as long as that information is contained in the note. EMRs that force a clinician to choose codes will see many clinicians typing a word, and simply selecting whatever is at the top of that list.
A coder or any qualified employee may absolutely change the CODE on the bill as long as it is supported in the record.
Or the clinician assigns 2 ICD10 codes that are excludes1. Again, a coder or any qualified employee may remove the excluded ICD10 code from the BILLING records (not the actual note).
Now, if the records indicate corpus luteum cyst of the right ovary, and to get a test paid, you assign an UNSUPPORTED ICD10, that is most definitely wrong. Fraud is what you could be fined for (and possibly worse).
Some employers expect the clinicians to code, but it is certainly not non-compliant or fraud to have other personnel assign/change/remove CODES from your billing. That is what certified coders are trained to do.