Wiki Changing ICD-9 & CPT Codes in the EMR Progress note

[maranieves]

The EMR system we use (eclinicalworks) has both the ICD-9 codes and CPT codes listed in the progress note. We have a great deal of problems when something is coded incorrectly by the providers because we have to send the note back to them for correction of the codes. To make the corrections they have to unlock their notes and then make any changes. What we need to know are there any actual laws against a coder making changes to a provider's coding in an electronic progress note. Specifically in this type of setting where the codes are part of the note.

Also, do the codes on the claim have to match the codes in the progress notes. Would it be ok if the coder just changed the coding on the claim?

 

[Pam Warren]

Can you create an addendum to a locked encounter? This is how we handle this problem. That way you're not overriding the original documentation without noting it's an addendum.

If the ICD-9 code in the documentation is incorrect, we absolutely ask for an addendum. If the CPT code, either LOS or procedure was incorrectly reported, that won't change the documentation, so we give an FYI to the provider, make a note in our billing system, and correct the code. Our notes say something like "Per audit by Mary Jones, Level of service meets 99214, changed on 7/28/2011 from 99215 and billed"
Or, if they report a 17000 and it should have been 17010, we note, "per audit by Mary Jones, procedure is documented as...."

check out this link for help with ammending a 'closed' medical record. http://campus.ahima.org/audio/2007/RB080907.pdf

 

[alasley]

The EMR system we use (eclinicalworks) has both the ICD-9 codes and CPT codes listed in the progress note. We have a great deal of problems when something is coded incorrectly by the providers because we have to send the note back to them for correction of the codes. To make the corrections they have to unlock their notes and then make any changes. What we need to know are there any actual laws against a coder making changes to a provider's coding in an electronic progress note. Specifically in this type of setting where the codes are part of the note.

Also, do the codes on the claim have to match the codes in the progress notes. Would it be ok if the coder just changed the coding on the claim?

While this may not answer your question, it seems like there would be an option in the EHR system to not display the codes in the note. Our physicians are on a different system. We have a lot of docs that like to use the E/M coder as a guide, but do not want it to display in the note. Therefore, we have shown them how to use the E/M coder but avoid the codes being documented in the note. Unfortunately in our system, we found that once it is documented, it cannot be removed.