Can a coder enter diagnoses codes in the progress note prior to office visit?

yanetsi

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Can a coder enter diagnoses codes under assessment prior to office visit (to remind providers to capture HCC codes)?

I've been asked by my supervisor to review charts prior to appt and in the assessment portion of the note enter all HCCS codes patient has in the problem list to remind providers address HCC codes. Is it ok to do that? Where can I find information about this.


Thank you so much.
 

trarut

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Only the physician should be making modifications to the actual progress note. I have never worked anywhere that allows anyone other than the physician to do that since it's the official documentation for the visit. How can the integrity of the note be maintained with multiple people allowed to modify the contents? I don't have any suggestions on where to find information to back this up because it's just a common sense hard no to me from a compliance standpoint. It shouldn't require anything to support that it's not the right thing to do. Perhaps another user on the forum can provide links to references for you.

We allow our coders to add, modify and terminate existing codes in the problem list in the electronic chart as they identify needed updates while reviewing documentation. They are not allowed to make any modifications to the notes and their permissions in the EHR wouldn't allow it anyway.
 

yanetsi

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Only the physician should be making modifications to the actual progress note. I have never worked anywhere that allows anyone other than the physician to do that since it's the official documentation for the visit. How can the integrity of the note be maintained with multiple people allowed to modify the contents? I don't have any suggestions on where to find information to back this up because it's just a common sense hard no to me from a compliance standpoint. It shouldn't require anything to support that it's not the right thing to do. Perhaps another user on the forum can provide links to references for you.

We allow our coders to add, modify and terminate existing codes in the problem list in the electronic chart as they identify needed updates while reviewing documentation. They are not allowed to make any modifications to the notes and their permissions in the EHR wouldn't allow it anyway.
Thank you for your response. You are right, it's common sense. :)
 

podcoder70

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I am going to respectfully disagree with trarut. Most offices have scribes that do the documentation for the physicians. Many offices also have in house coders that work directly with the physicians in completion of the progress notes. So to answer your question, it is completely appropriate if that is the relationship you have with that physician. Ultimately, that physician would then review and sign the document.

For example, in my office, I code from progress notes, not from a superbill. If the doctor is missing information in the encounter note, I message them on ways to improve the document. They then open the note and fix it and resign it. In other examples, the note is not signed yet and the doctor has me go in and add the necessary codes to the encounter, then they review and sign.

Just my humble opinion...
 

trarut

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Disagreement taken respectfully, podcoder70 :) That's the benefit of being on the forum and sharing our experiences. From my experiences in the office and outpatient settings, a coder has never been permitted to modify the provider documentation. Nor have I worked anywhere that employs scribes so that adds another element to the discussion. I'm glad someone else chimed in because it's good to have the additional perspectives.
 

csperoni

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Here's my take on the situation regarding documentation:
Scribes - absolutely yes. They were present in the room and their responsibility is to document the discussion and care that took place, which the clinician will sign off on.
Coders - very gray area. Coders should absolutely be allowed to make any code decisions, but should not be adding/changing/removing medical documentation. From my experience, if the documentation were unclear, the coder would ask the doctor to amend/correct the documentation. There is no requirement for codes to be in the medical documentation, but many EHR systems have that built in.
For example, if the note stated "Malignant neoplasm of the left ovary C56.9", the coder may adjust the billing system to C56.2 which is the correct code for the laterality. Neither the clinician nor the coder NEEDS to change the C56.9 in the documentation to C56.2. If I do see a repeating trend like this, I will educate my clinicians. In many EHR systems, when the clinician types in a key word for the diagnosis, they will simply pick the code at the top of the list, even if it's not the correct code. As long as the note is clear what the actual diagnosis is, the code may be corrected by other staff, without a need to amend/modify the medical document.
 

carlystur

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In many EHR systems, when the clinician types in a key word for the diagnosis, they will simply pick the code at the top of the list, even if it's not the correct code. As long as the note is clear what the actual diagnosis is, the code may be corrected by other staff, without a need to amend/modify the medical document.
The doctors I work for will only pick the codes as their diagnoses using eClinicalWorks, which makes it harder for me since they often don't put their diagnoses in their documentation for me to confirm they've chosen the correct codes! Very frustrating!
 

yanetsi

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Thank you for taking the time to share your feedback. :)
Thankfully after a few emails between the providers and coders (me) they decided not to make this change. I work in an office where providers work with scribes, at the end of the note scribe/provider add statement documenting physician dictated the note.
Also, progress notes have internal logs (audit trails) showing who entered documentation in the note. Coders are not clinicians and conditions/diagnoses can only be recommended/captured based on providers documentation.
 
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