Wiki Can a CPC assign and/or correct CPT/ICD-10 codes?

[kfitz2606]

Can a CPC assign and/or correct CPT-ICD-10 codes as long as the providers documentation supports this or does it have to go back to the provider? Everywhere I have worked we only sent this type of information back to the provider if the OV note was not clear/specific and we were unable to code based off the OV note. What is everyone else doing?

 

[sls314]

Can a CPC assign and/or correct CPT-ICD-10 codes as long as the providers documentation supports this or does it have to go back to the provider? Everywhere I have worked we only sent this type of information back to the provider if the OV note was not clear/specific and we were unable to code based off the OV note. What is everyone else doing?

Yes, as coders we are trained to code based on the documentation, and that's how I do my job.

Do some employers impose what I consider to be unreasonable restrictions on that? Unfortunately, yes.

I don’t understand why a practice would implement an internal policy requiring providers to be repeatedly contacted, even when the documentation is perfectly clear. But it happens. I don’t agree with it, but it happens.

Personally, I wouldn’t want to work somewhere that required me to go back to the physician to change an unspecified code to a laterality-specific code when the laterality was already clearly documented in the note—and yet, I’ve heard of coders who had to jump through hoops like that.

That’s why I love coding for our locum who does vacation coverage. He doesn’t assign any diagnosis codes at all, and I get to code strictly based on the documentation. It’s exactly how coding should be, in my opinion.

diagnosis codes, diagnosis coding

 

[Sarah Ann]

"Can a CPC assign and/or correct CPT-ICD-10 codes as long as the providers documentation supports this" YES!

diagnosis codes, diagnosis coding