Auditing EHR notes

vkratzer

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Not sure how to handle this. I review physician notes in the EHR before sending to the Billing Team. My problem is that the physicians diagnosis code does not match his documentation. Example. Breast surgeon sees patient who was diagnosed and treated for breast cancer 5 years previously. The patient returns for yearly visit. Patient has no evidence of cancer and treatment is complete. The physician continues to use the breast cancer diagnosis. His notes are very specific as to post surgical treatment including radiation, chemo, and hormonal therapy, mastectomy, etc. I have been editing the diagnosis to appropriate v-codes. My question is if the chart were to be audited and I changed the code to personal history and the physician is using the breast cx diagnosis in his assessment, would that be a problem because the diagnosis code submitted to insurance does not match the physician's dx code in the EHR.
 

lburke31

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Is the md aware you are changing the codes? I code for pediatrics so your question is not not relative to anything i do. However it is considered a coding error on an audit if the dx does not match the documentation. I don't have my icd9 at home to check but isn't there a guideline with the code whether it is for an active or inactive state? I would also post this ? Under the oncology forum.i would never recode a charge w/o the md's approval but i would certainly provide them with written proof. Ask the opinion of someone in your local medical society. Ours is very helpful to our office when there is a difference of opinion between the coder (me) and the provider. A good reference book to have around is the ama's medical record auditor. Regards lburke cpedc
 
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